Provider Demographics
NPI:1922186949
Name:TIEDEMANN-FULLER, PAMELA MEGHAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:MEGHAN
Last Name:TIEDEMANN-FULLER
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: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:
Practice Address - Street 1:3260 BEARD RD
Practice Address - Street 2:SUITE 4
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-3423
Practice Address - Country:US
Practice Address - Phone:707-556-2356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23513103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical