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General NPI Number Information
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NPI Number | 1740556489
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Entity Type | Organization
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Legal Business Name | NORTH BAY PSYCHOLOGY
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Dates
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Enumeration Date | 03/27/2012
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Last Update Date | 03/27/2012
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Provider Practice Location Address
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Address Line | 1763 2ND ST
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City | NAPA
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State | CA
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Zip | 94559-2407
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Country | US
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Telephone | 707-556-2356
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Fax | 707-256-3553
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Provider Business Mailing Address
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Address Line | PO BOX 5524
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City | NAPA
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State | CA
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Zip | 94581-0524
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Country | US
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Telephone | 707-556-2356
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Fax | 707-256-3553
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Authorized Official
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Title or Position | LICENSED CLINICAL PSYCHOLOGIST
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Name | PAMELA MEGHAN TIEDEMANN-FULLER
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Credential | PHD
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Telephone | 707-556-2356
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY23513
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License Number State | CA
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