Healthcare Provider Details

I. General information

NPI: 1700107521
Provider Name (Legal Business Name): EDRA SPEVACK N.D., CBHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 IRVING ST SUITE 104
SAN FRANCISCO CA
94122-2206
US

IV. Provider business mailing address

425 BUCHANAN STREET
SAN FRANCISCO CA
94102-5529
US

V. Phone/Fax

Practice location:
  • Phone: 415-742-1743
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberND-370
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: