Provider Demographics
NPI:1013262906
Name:LARA WEYLAND, PH.D., CLINICAL PSYCHOLOGY, INC.
Entity Type:Organization
Organization Name:LARA WEYLAND, PH.D., CLINICAL PSYCHOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARA
Authorized Official - Middle Name:ADELINE
Authorized Official - Last Name:WEYLAND
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:510-534-5354
Mailing Address - Street 1:2220 MOUNTAIN BLVD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-2958
Mailing Address - Country:US
Mailing Address - Phone:510-531-5354
Mailing Address - Fax:510-222-3508
Practice Address - Street 1:2220 MOUNTAIN BLVD
Practice Address - Street 2:SUITE 240
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-2958
Practice Address - Country:US
Practice Address - Phone:510-531-5354
Practice Address - Fax:510-222-3508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-17
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14852103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY148520Medicare PIN
CA8438829Medicare UPIN