Provider Demographics
NPI:1609925858
Name:WOTKYNS, JOHN G (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:WOTKYNS
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 1:2927 WHEELER ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-1810
Mailing Address - Country:US
Mailing Address - Phone:510-549-1484
Mailing Address - Fax:
Practice Address - Street 1:2500 BISSELL AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-1815
Practice Address - Country:US
Practice Address - Phone:510-231-3917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17268103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical