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General NPI Number Information
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NPI Number | 1417608068
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Entity Type | Organization
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Legal Business Name | FAWCETT PSYCHOLOGY, INC.
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Dates
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Enumeration Date | 01/14/2022
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Last Update Date | 01/14/2022
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Provider Practice Location Address
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Address Line | 3604 4TH AVE STE 5
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City | SAN DIEGO
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State | CA
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Zip | 92103-4118
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Country | US
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Telephone | 619-356-0811
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Fax |
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Provider Business Mailing Address
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Address Line | 4625 SANTA MONICA AVE
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City | SAN DIEGO
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State | CA
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Zip | 92107-2907
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Country | US
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Telephone | 619-306-0811
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | KEVIN FAWCETT
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Credential | PH.D.
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Telephone | 619-306-0811
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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