Healthcare Provider Details

I. General information

NPI: 1720375975
Provider Name (Legal Business Name): MICHELLE WYSOPAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15501 SAN PABLO AVE
RICHMOND CA
94806-5704
US

IV. Provider business mailing address

18801 SAN PABLO AVE G317
RICHMOND CA
94609-5704
US

V. Phone/Fax

Practice location:
  • Phone: 888-524-5122
  • Fax:
Mailing address:
  • Phone: 888-524-5122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: