Healthcare Provider Details

I. General information

NPI: 1821580143
Provider Name (Legal Business Name): ANN RYAN WYCOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 06/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1565 HOTEL CIR S STE 310
SAN DIEGO CA
92108
US

IV. Provider business mailing address

1565 HOTEL CIR S STE 310
SAN DIEGO CA
92108-3419
US

V. Phone/Fax

Practice location:
  • Phone: 619-295-8005
  • Fax:
Mailing address:
  • Phone: 619-295-8005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY14223
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: