Provider Demographics
NPI:1326298746
Name:WOLTERS, PATRICE RUTH (PHD)
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:RUTH
Last Name:WOLTERS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 CAPITOLA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-2794
Mailing Address - Country:US
Mailing Address - Phone:831-457-7775
Mailing Address - Fax:
Practice Address - Street 1:519 CAPITOLA AVE STE B
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-2794
Practice Address - Country:US
Practice Address - Phone:831-457-7775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-22
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8100103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical