=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619617842
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW TARDIFF PSYD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2022
-----------------------------------------------------
Last Update Date | 06/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1950 ALAMEDA DE LAS PULGAS
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94403-1222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-372-6114
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5432 GEARY BLVD # 226
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94121-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-345-7993
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | PSY31920
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------