Healthcare Provider Details

I. General information

NPI: 1376305664
Provider Name (Legal Business Name): WELLNESS WITHIN PSYCHOTHERAPY & CONSULTING PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2024
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 E PROSPECT AVE STE 2A
DANVILLE CA
94526-3866
US

IV. Provider business mailing address

604 MILITARY E
BENICIA CA
94510-3551
US

V. Phone/Fax

Practice location:
  • Phone: 510-982-1000
  • Fax: 510-210-9310
Mailing address:
  • Phone: 707-908-0617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. NORVAL JOSEPH HICKMAN III
Title or Position: PRESIDENT & CEO
Credential: PHD, MPH
Phone: 707-908-0617