Provider Demographics
NPI:1699705053
Name:FRY, MARK F (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:F
Last Name:FRY
Suffix:
Gender:M
Credentials:PHD
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Other - First Name:
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Mailing Address - Street 1:2970 CAMINO DIABLO STE 300
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-4001
Mailing Address - Country:US
Mailing Address - Phone:925-282-1778
Mailing Address - Fax:415-296-5299
Practice Address - Street 1:2970 CAMINO DIABLO STE 300
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94597-4001
Practice Address - Country:US
Practice Address - Phone:925-282-1778
Practice Address - Fax:415-296-5299
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 19332103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY 193320Medicaid
CAPSY 193320Medicaid