1649202300 NPI number — DR. WILLIE G WEDDINGTON ED. D. PSYCHOLOGY

Table of content: DR. WILLIE G WEDDINGTON ED. D. PSYCHOLOGY (NPI 1649202300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649202300 NPI number — DR. WILLIE G WEDDINGTON ED. D. PSYCHOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEDDINGTON
Provider First Name:
WILLIE
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
ED. D. PSYCHOLOGY
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WEDDINGTON
Provider Other First Name:
BILL
Provider Other Middle Name:
G.
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
ED. D. PSYCHOLOGY
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1649202300
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
532 OREGON STREET
Provider Second Line Business Mailing Address:
SUITE 10
Provider Business Mailing Address City Name:
VALLEJO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94590
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-224-5332
Provider Business Mailing Address Fax Number:
707-224-5332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
532 OREGON ST
Provider Second Line Business Practice Location Address:
SUITE 10
Provider Business Practice Location Address City Name:
VALLEJO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94590-3254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-224-5332
Provider Business Practice Location Address Fax Number:
707-224-5332
Provider Enumeration Date:
07/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY9967 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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