Healthcare Provider Details

I. General information

NPI: 1538556865
Provider Name (Legal Business Name): TLC BEHAVIORAL HEALTH AND PSYCHOLOGY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 MARINA VILLAGE PARKWAY SUITE 100
ALAMEDA CA
94501-1078
US

IV. Provider business mailing address

1080 MARINA VILLAGE PARKWAY SUITE 100
ALAMEDA CA
94501-1078
US

V. Phone/Fax

Practice location:
  • Phone: 510-337-7950
  • Fax: 510-337-7969
Mailing address:
  • Phone: 510-337-7950
  • Fax: 510-337-7969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL WIEDERSTEIN
Title or Position: CEO, CFO
Credential:
Phone: 510-337-7950