Provider Demographics
NPI:1508967142
Name:BRISCOE, YOLANDA BASOCO (PSYD)
Entity Type:Individual
Prefix:DR
First Name:YOLANDA
Middle Name:BASOCO
Last Name:BRISCOE
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 1:1179 N MCDOWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-6559
Mailing Address - Country:US
Mailing Address - Phone:707-559-7500
Mailing Address - Fax:707-559-7620
Practice Address - Street 1:1179 N MCDOWELL BLVD
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-6559
Practice Address - Country:US
Practice Address - Phone:707-559-7500
Practice Address - Fax:707-559-7620
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0920103T00000X
CAPSY19649103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM4753852Medicaid