MEDICARE: DR. MICHAEL WYDO PSY.D., ABPP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TB0200X	Cognitive & Behavioral Psychologist	20171	CA

General Provider Information

NPI Number	:	1104287325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL WYDO PSY.D., ABPP

Provider Business Mailing Address
First Line	:	5092 FLAMINGO CIR
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92649-1408
Country	:	US
Telephone Number	:	919-521-1835
Fax Number	:

Provider Business Practice Location Address
First Line	:	5092 FLAMINGO CIR
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92649-1408
Country	:	US
Telephone Number	:	919-521-1835
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2016
Last Update Date	:	03/15/2016

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