Healthcare Provider Details

I. General information

NPI: 1649510223
Provider Name (Legal Business Name): JULIE M WOLTIL PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2013
Last Update Date: 07/24/2025
Certification Date: 07/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1426 AVIATION BLVD SUITE 103
REDONDO BEACH CA
90278-4002
US

IV. Provider business mailing address

7195 THORNAPPLE RIVER DR SE
ADA MI
49301-8411
US

V. Phone/Fax

Practice location:
  • Phone: 310-372-4245
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSD36578
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301019684
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: