Provider Demographics
NPI:1336295500
Name:TWEEDY, DAVID GLEN (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:GLEN
Last Name:TWEEDY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2945 HARDING ST.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008
Mailing Address - Country:US
Mailing Address - Phone:760-434-3443
Mailing Address - Fax:760-434-3684
Practice Address - Street 1:2945 HARDING ST.
Practice Address - Street 2:SUITE 100
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008
Practice Address - Country:US
Practice Address - Phone:760-434-3443
Practice Address - Fax:760-434-3684
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16608103TA0700X, 103TC0700X, 103TC2200X
103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP16608Medicare ID - Type UnspecifiedPROVIDER NUMBER