Healthcare Provider Details

I. General information

NPI: 1861069460
Provider Name (Legal Business Name): TONYA WAECHTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 PORTOLA DR STE 108
SAN FRANCISCO CA
94127-1234
US

IV. Provider business mailing address

95 LONGVIEW DR
DALY CITY CA
94015-4717
US

V. Phone/Fax

Practice location:
  • Phone: 415-674-7504
  • Fax:
Mailing address:
  • Phone: 916-955-0798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number41353
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: