Healthcare Provider Details

I. General information

NPI: 1598875643
Provider Name (Legal Business Name): VIRGINA C WULF PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 MAIN ST SUTIE 500
VANCOUVER WA
98660
US

IV. Provider business mailing address

1104 MAIN ST SUTIE 500
VANCOUVER WA
98660
US

V. Phone/Fax

Practice location:
  • Phone: 360-993-5351
  • Fax: 503-645-2224
Mailing address:
  • Phone: 360-993-5351
  • Fax: 503-645-2224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY00001579
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: