Healthcare Provider Details

I. General information

NPI: 1760591499
Provider Name (Legal Business Name): SANDRA WILLARD PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 POTRERO AVE
SAN FRANCISCO CA
94110-3518
US

IV. Provider business mailing address

2550 23RD ST
SAN FRANCISCO CA
94110-3504
US

V. Phone/Fax

Practice location:
  • Phone: 415-206-5270
  • Fax: 415-206-4722
Mailing address:
  • Phone: 415-206-5270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 17409
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: