Provider Demographics
NPI:1588702740
Name:FAHY, JOHN FERGUS (PHD)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:FERGUS
Last Name:FAHY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:MR
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:FAHY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:2001 DWIGHT WAY
Mailing Address - Street 2:5 NORTH
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-2608
Mailing Address - Country:US
Mailing Address - Phone:510-204-4896
Mailing Address - Fax:510-204-4655
Practice Address - Street 1:2001 DWIGHT WAY
Practice Address - Street 2:5 NORTH
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-2608
Practice Address - Country:US
Practice Address - Phone:510-204-4896
Practice Address - Fax:510-204-4655
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14056103TR0400X, 103T00000X, 103G00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy