MEDICARE: DR. CAROL G WEISS PHD

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	15440	CA

General Provider Information

NPI Number	:	1326031683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAROL G WEISS PHD

Provider Business Mailing Address
First Line	:	1001 HERMOSA AVE
Second Line	:
City	:	HERMOSA BEACH
State	:	CA
Zip	:	90254-3781
Country	:	US
Telephone Number	:	310-374-5191
Fax Number	:	310-798-2197

Provider Business Practice Location Address
First Line	:	1001 HERMOSA AVE
Second Line	:
City	:	HERMOSA BEACH
State	:	CA
Zip	:	90254-3781
Country	:	US
Telephone Number	:	310-374-5191
Fax Number	:	310-798-2197

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

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	07/08/2007

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