MEDICARE: WHOLE CHILD PSYCHOLOGICAL SERVICES, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	PSY22017	CA
2	252Y00000X	Early Intervention Provider Agency
3	251S00000X	Community/Behavioral Health Agency	PSY22017	CA

General Provider Information

NPI Number	:	1003150830
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHOLE CHILD PSYCHOLOGICAL SERVICES, PC

Provider Business Mailing Address
First Line	:	2110 6TH ST
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94710-2243
Country	:	US
Telephone Number	:	510-847-8797
Fax Number	:

Provider Business Practice Location Address
First Line	:	2110 6TH ST
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94710-2243
Country	:	US
Telephone Number	:	510-847-8797
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. LAUREN TOLK
Credential	:	PSY.D.
Telephone Number	:	510-847-8797

Provider Enumeration Date	:	11/16/2012
Last Update Date	:	11/16/2012

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