Provider Demographics
NPI:1518008630
Name:WOLFSON, JOHANNA (PHD)
Entity Type:Individual
Prefix:MS
First Name:JOHANNA
Middle Name:
Last Name:WOLFSON
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 1:509 GOLDEN GATE AVENUE
Mailing Address - Street 2:
Mailing Address - City:POINT RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94801
Mailing Address - Country:US
Mailing Address - Phone:510-604-1734
Mailing Address - Fax:
Practice Address - Street 1:820 LAS GALLINAS AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903
Practice Address - Country:US
Practice Address - Phone:415-444-3034
Practice Address - Fax:415-444-3019
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8961103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist