Provider Demographics
NPI:1982675930
Name:PURDY, ANNELIE S (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANNELIE
Middle Name:S
Last Name:PURDY
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 1:433 S LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-5525
Mailing Address - Country:US
Mailing Address - Phone:805-349-9706
Mailing Address - Fax:805-349-0576
Practice Address - Street 1:433 S LINCOLN ST
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458-5525
Practice Address - Country:US
Practice Address - Phone:805-349-9706
Practice Address - Fax:805-349-0576
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-29
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5452103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL5452Medicaid
CAPSY5452OtherSTATE LICENSING NO.
CAPSY5452OtherSTATE LICENSING NO.
CACP5452Medicare ID - Type UnspecifiedSOUTHERN CAL. PROVIDER NO