Healthcare Provider Details

I. General information

NPI: 1336472588
Provider Name (Legal Business Name): WILL COURTENAY PHD, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2009
Last Update Date: 09/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2811 COLLEGE AVE STE 1
BERKELEY CA
94705-2167
US

IV. Provider business mailing address

2811 COLLEGE AVE STE 1
BERKELEY CA
94705-2167
US

V. Phone/Fax

Practice location:
  • Phone: 415-346-6719
  • Fax:
Mailing address:
  • Phone: 415-346-6719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS16854
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: