MEDICARE: DR. PAUL K CHITWOOD PHD

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	103TA0400X	Addiction (Substance Use Disorder) Psychologist	PSY14963	CA
2	103TC0700X	Clinical Psychologist	PSY14963	CA
3	103TP2701X	Group Psychotherapy Psychologist	PSY14963	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PSY14963	OTHER	CA	STATE OF CALIFORNIA

General Provider Information

NPI Number	:	1932584539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAUL K CHITWOOD PHD

Provider Business Mailing Address
First Line	:	4811 CHIPPENDALE DR
Second Line	:	# 302
City	:	SACRAMENTO
State	:	CA
Zip	:	95841-2555
Country	:	US
Telephone Number	:	916-349-9403
Fax Number	:

Provider Business Practice Location Address
First Line	:	4811 CHIPPENDALE DR
Second Line	:	# 302
City	:	SACRAMENTO
State	:	CA
Zip	:	95841-2555
Country	:	US
Telephone Number	:	916-349-9403
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2015
Last Update Date	:	02/11/2022

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