Healthcare Provider Details

I. General information

NPI: 1558694174
Provider Name (Legal Business Name): SHAWNEE LW CUZZILLO PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 09/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 SOLANO AVE
ALBANY CA
94706-1826
US

IV. Provider business mailing address

1304 SOLANO AVE
ALBANY CA
94706-1826
US

V. Phone/Fax

Practice location:
  • Phone: 510-525-8013
  • Fax: 510-525-8013
Mailing address:
  • Phone: 510-525-8013
  • Fax: 510-525-8013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY13369
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: