Healthcare Provider Details

I. General information

NPI: 1306868518
Provider Name (Legal Business Name): JOHN WEIR PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 06/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 D ST #209
SAN RAFAEL CA
94901-3707
US

IV. Provider business mailing address

200 FORBES AVE
SAN ANSELMO CA
94960-2314
US

V. Phone/Fax

Practice location:
  • Phone: 415-457-8886
  • Fax:
Mailing address:
  • Phone: 415-457-8886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY5615
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberPSY5615
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY5615
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: