MEDICARE: LAURA JEANETTE WILHOIT PH.D.

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 26656	CA
2	103TC0700X	Clinical Psychologist	PSY26656	CA

General Provider Information

NPI Number	:	1649497637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA JEANETTE WILHOIT PH.D.

Provider Business Mailing Address
First Line	:	4290 POLK AVENUE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92105-1524
Country	:	US
Telephone Number	:	619-563-0507
Fax Number	:	619-563-0015

Provider Business Practice Location Address
First Line	:	11835 CARMEL MOUNTAIN RD STE 1304-243
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92128-4609
Country	:	US
Telephone Number	:	858-880-8642
Fax Number	:

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

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	09/24/2022

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