Healthcare Provider Details

I. General information

NPI: 1679587109
Provider Name (Legal Business Name): RONALD BRENT FARNSWORTH PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 MEDICAL DR STE 330
SAN ANTONIO TX
78229-5805
US

IV. Provider business mailing address

15318 MCKAYS LARK
SAN ANTONIO TX
78253-6507
US

V. Phone/Fax

Practice location:
  • Phone: 210-614-4990
  • Fax: 210-614-4991
Mailing address:
  • Phone: 203-641-1995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number002055
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: