Provider Demographics
NPI:1497901391
Name:KIRK R. WACHTMANN, PH.D., APC
Entity Type:Organization
Organization Name:KIRK R. WACHTMANN, PH.D., APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WACHTMANN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:619-977-6007
Mailing Address - Street 1:4060 FOURTH AVE
Mailing Address - Street 2:SUITE 615
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2116
Mailing Address - Country:US
Mailing Address - Phone:619-977-6007
Mailing Address - Fax:
Practice Address - Street 1:4060 FOURTH AVE
Practice Address - Street 2:SUITE 615
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2116
Practice Address - Country:US
Practice Address - Phone:619-977-6007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-11
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5830103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty