Healthcare Provider Details

I. General information

NPI: 1124105085
Provider Name (Legal Business Name): KENNETH R. WULFF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 SPRING HILL RD
PETALUMA CA
94952-9305
US

IV. Provider business mailing address

1503 SPRING HILL RD
PETALUMA CA
94952-9305
US

V. Phone/Fax

Practice location:
  • Phone: 707-559-3895
  • Fax:
Mailing address:
  • Phone: 707-559-3895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberG32683
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: