Provider Demographics
NPI:1407475833
Name:MCCAN, DWIGHT OWEN (PHD)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:OWEN
Last Name:MCCAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3424 VICTOR AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-4028
Mailing Address - Country:US
Mailing Address - Phone:510-378-8700
Mailing Address - Fax:
Practice Address - Street 1:3424 VICTOR AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-4028
Practice Address - Country:US
Practice Address - Phone:510-530-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA273102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1170154882OtherUNITED STATES UNIFORMED SERVICES