Healthcare Provider Details

I. General information

NPI: 1710383872
Provider Name (Legal Business Name): AMY WYSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2014
Last Update Date: 11/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 E GOBBI ST
UKIAH CA
95482-5511
US

IV. Provider business mailing address

350 E GOBBI ST
UKIAH CA
95482-5511
US

V. Phone/Fax

Practice location:
  • Phone: 707-472-2922
  • Fax:
Mailing address:
  • Phone: 707-472-2922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: