Healthcare Provider Details

I. General information

NPI: 1386984862
Provider Name (Legal Business Name): SAM RUTHERFORD MCDILL JR. PHD.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2013
Last Update Date: 02/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

END RTE 202 TEHACHAPI
TEHACHAPI CA
93561-3561
US

IV. Provider business mailing address

PO BOX 1031
TEHACHAPI CA
93581-1031
US

V. Phone/Fax

Practice location:
  • Phone: 661-822-4402
  • Fax: 661-823-3339
Mailing address:
  • Phone: 661-822-4402
  • Fax: 661-823-3339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY12096
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: