MEDICARE: DR. WESLEY PEDERSON 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	103T00000X	Psychologist	PSY26040	CA

General Provider Information

NPI Number	:	1598194227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WESLEY PEDERSON PHD

Provider Business Mailing Address
First Line	:	617 VETERANS BLVD
Second Line	:	SUITE 204
City	:	REDWOOD CITY
State	:	CA
Zip	:	94063-1496
Country	:	US
Telephone Number	:	650-804-8739
Fax Number	:

Provider Business Practice Location Address
First Line	:	617 VETERANS BLVD
Second Line	:	SUITE 204
City	:	REDWOOD CITY
State	:	CA
Zip	:	94063-1496
Country	:	US
Telephone Number	:	650-804-8739
Fax Number	:

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

Provider Enumeration Date	:	11/04/2013
Last Update Date	:	08/11/2014

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