Provider Demographics
NPI:1396179859
Name:WOOLLUM, EMILY KRUGER (PSYD)
Entity type:Individual
Prefix:DR
First Name:EMILY
Middle Name:KRUGER
Last Name:WOOLLUM
Suffix:
Gender:F
Credentials:PSYD
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 93
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94543-0093
Mailing Address - Country:US
Mailing Address - Phone:510-629-1055
Mailing Address - Fax:
Practice Address - Street 1:31219 FAIRCLIFF ST
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544-7445
Practice Address - Country:US
Practice Address - Phone:510-629-1055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-02
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY30871103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical