Provider Demographics
NPI:1881654846
Name:FENTON, MICHAEL (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:FENTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 QUAIL ST
Mailing Address - Street 2:SUITE 170
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2731
Mailing Address - Country:US
Mailing Address - Phone:949-833-7933
Mailing Address - Fax:949-833-3963
Practice Address - Street 1:1000 QUAIL ST
Practice Address - Street 2:SUITE 170
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2839
Practice Address - Country:US
Practice Address - Phone:949-833-7933
Practice Address - Fax:949-833-3963
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY9254103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY092540Medicaid
CACP9254Medicare ID - Type Unspecified