Healthcare Provider Details

I. General information

NPI: 1740620277
Provider Name (Legal Business Name): NEIL MARTIN WAUGH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2013
Last Update Date: 06/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24863 W JAYNE AVE
COALINGA CA
93210-9502
US

IV. Provider business mailing address

24863 W JAYNE AVE
COALINGA CA
93210-9502
US

V. Phone/Fax

Practice location:
  • Phone: 559-935-4900
  • Fax:
Mailing address:
  • Phone: 559-935-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number16924
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: