Healthcare Provider Details

I. General information

NPI: 1831362011
Provider Name (Legal Business Name): CAROL VISSER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 EAST ST
AUBURN CA
95603-5119
US

IV. Provider business mailing address

122 EAST ST
AUBURN CA
95603-5119
US

V. Phone/Fax

Practice location:
  • Phone: 530-889-8480
  • Fax:
Mailing address:
  • Phone: 530-889-8480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY8619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: