Provider Demographics
NPI:1598194227
Name:PEDERSON, WESLEY (PHD)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:
Last Name:PEDERSON
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 1:617 VETERANS BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-1496
Mailing Address - Country:US
Mailing Address - Phone:650-804-8739
Mailing Address - Fax:
Practice Address - Street 1:617 VETERANS BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-1496
Practice Address - Country:US
Practice Address - Phone:650-804-8739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26040103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist