Healthcare Provider Details

I. General information

NPI: 1255789913
Provider Name (Legal Business Name): SENECA EDWARD SHARP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2016
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 ALTA RD
SAN DIEGO CA
92179-0001
US

IV. Provider business mailing address

237 W LAKELAWN PL APT 6
MADISON WI
53703-1280
US

V. Phone/Fax

Practice location:
  • Phone: 619-661-6500
  • Fax:
Mailing address:
  • Phone: 530-304-5761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY31629
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: