Provider Demographics
NPI:1740556489
Name:NORTH BAY PSYCHOLOGY
Entity Type:Organization
Organization Name:NORTH BAY PSYCHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:MEGHAN
Authorized Official - Last Name:TIEDEMANN-FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:707-556-2356
Mailing Address - Street 1:PO BOX 5524
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94581-0524
Mailing Address - Country:US
Mailing Address - Phone:707-556-2356
Mailing Address - Fax:707-256-3553
Practice Address - Street 1:1763 2ND ST
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559-2407
Practice Address - Country:US
Practice Address - Phone:707-556-2356
Practice Address - Fax:707-256-3553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23513103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty