Basic Information
| Provider Information | |||||||||
| NPI: | 1659832186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEIL | ||||||||
| FirstName: | DOUGLAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5714 GASKILL ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946082716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102899633 | ||||||||
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| Practice Location | |||||||||
| Address1: | 401 ROLAND WAY | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946212034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108393800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2019 | ||||||||
| LastUpdateDate: | 06/26/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | CA | N | Agencies | Case Management | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 101YM0800X | 05 | CA | MEDICAID |