Provider Demographics
NPI:1972838464
Name:SELF, JOANNA F (PHD)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:F
Last Name:SELF
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 1:3629 GRAND AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-2009
Mailing Address - Country:US
Mailing Address - Phone:510-847-8139
Mailing Address - Fax:510-452-0300
Practice Address - Street 1:3629 GRAND AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-2009
Practice Address - Country:US
Practice Address - Phone:510-847-8139
Practice Address - Fax:510-452-0300
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-16
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16660103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical