MEDICARE: DR. DIANE ROSEMARY WULFSOHN 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	1687	GA

General Provider Information

NPI Number	:	1760532527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIANE ROSEMARY WULFSOHN PHD

Provider Business Mailing Address
First Line	:	5775 PEACHTREE DUNWOODY RD NE
Second Line	:	C200
City	:	ATLANTA
State	:	GA
Zip	:	30342-1556
Country	:	US
Telephone Number	:	770-883-4391
Fax Number	:	404-256-2795

Provider Business Practice Location Address
First Line	:	5775 PEACHTREE DUNWOODY RD NE
Second Line	:	C200
City	:	ATLANTA
State	:	GA
Zip	:	30342-1556
Country	:	US
Telephone Number	:	770-883-4391
Fax Number	:	404-256-2795

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

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	07/08/2007

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