Provider Demographics
NPI:1033580329
Name:HENNEMUTH, GARY (PSYD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:HENNEMUTH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 18TH ST STE 507
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-2077
Mailing Address - Country:US
Mailing Address - Phone:415-617-9323
Mailing Address - Fax:
Practice Address - Street 1:1918 UNIVERSITY AVE STE 201
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-3264
Practice Address - Country:US
Practice Address - Phone:510-548-9716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2023-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY33414103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist