Healthcare Provider Details

I. General information

NPI: 1124809793
Provider Name (Legal Business Name): PATHWAVE PSYCHIATRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2023
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1270 CAMPUS DR
BERKELEY CA
94708-2045
US

IV. Provider business mailing address

1270 CAMPUS DR
BERKELEY CA
94708-2045
US

V. Phone/Fax

Practice location:
  • Phone: 617-299-9383
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: SAHAB YAQUBI
Title or Position: CEO
Credential: MD
Phone: 510-925-1230