Basic Information
| Provider Information | |||||||||
| NPI: | 1962601765 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PSYCHOPHARMACOLOGY CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHILDREN'S HOSPITAL & RESEARCH CENTER AT OAKLAND | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 747 52ND ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946091809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104283885 | ||||||||
| FaxNumber: | 5105977171 | ||||||||
| Practice Location | |||||||||
| Address1: | 5220 CLAREMONT AVE | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946181033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104283351 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2007 | ||||||||
| LastUpdateDate: | 07/12/2007 | ||||||||
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| AuthorizedOfficialLastName: | NORTHCUTT | ||||||||
| AuthorizedOfficialFirstName: | CHERISE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF MENTAL HEALTH SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 5104283885 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PH.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.