MEDICARE: DR. DODY J. REUSTLE PSYD

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	103TC0700X	Clinical Psychologist	PSY 23886	CA

General Provider Information

NPI Number	:	1306147350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DODY J. REUSTLE PSYD

Provider Business Mailing Address
First Line	:	711 JEFFERSON STREET
Second Line	:	SUITE 202
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-5556
Country	:	US
Telephone Number	:	707-342-3639
Fax Number	:	707-427-2262

Provider Business Practice Location Address
First Line	:	711 JEFFERSON STREET
Second Line	:	SUITE 202
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-5556
Country	:	US
Telephone Number	:	707-342-3639
Fax Number	:	707-427-2262

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

Provider Enumeration Date	:	11/08/2010
Last Update Date	:	07/30/2019

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