Healthcare Provider Details

I. General information

NPI: 1760532527
Provider Name (Legal Business Name): DIANE ROSEMARY WULFSOHN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5775 PEACHTREE DUNWOODY RD NE C200
ATLANTA GA
30342-1556
US

IV. Provider business mailing address

5775 PEACHTREE DUNWOODY RD NE C200
ATLANTA GA
30342-1556
US

V. Phone/Fax

Practice location:
  • Phone: 770-883-4391
  • Fax: 404-256-2795
Mailing address:
  • Phone: 770-883-4391
  • Fax: 404-256-2795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1687
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: