Provider Demographics
NPI:1093959256
Name:DEWEESE, SARAH (PSYD)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:DEWEESE
Suffix:
Gender:F
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:PO BOX 2
Mailing Address - Street 2:
Mailing Address - City:SAN QUENTIN
Mailing Address - State:CA
Mailing Address - Zip Code:94964-0002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 MAIN ST
Practice Address - Street 2:SAN QUENTIN STATE PRISON
Practice Address - City:SAN QUENTIN
Practice Address - State:CA
Practice Address - Zip Code:94964-1000
Practice Address - Country:US
Practice Address - Phone:415-454-1460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-30
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22657103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PSY22657OtherPSYCHOLOGY LICENSE