=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124271184
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDALL CRAIG WYATT PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2008
-----------------------------------------------------
Last Update Date | 04/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4283 PIEDMONT AVE
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94611-4758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-610-1097
-----------------------------------------------------
Fax | 415-955-2179
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 BEACH ST STE 100
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94133-1221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-955-2076
-----------------------------------------------------
Fax | 415-955-2179
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY1220
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------