Healthcare Provider Details

I. General information

NPI: 1306588173
Provider Name (Legal Business Name): CAROLYN RESNER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31625 HIGHWAY 101 S
SOLEDAD CA
93960-9529
US

IV. Provider business mailing address

5875 ETTERSBERG DR
SAN JOSE CA
95123-3514
US

V. Phone/Fax

Practice location:
  • Phone: 831-678-5500
  • Fax:
Mailing address:
  • Phone: 708-341-5106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY35198
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: