Provider Demographics
NPI:1396978466
Name:CONDYLIS, LAURA M (PSYD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:M
Last Name:CONDYLIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:FELTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3871 HOWE ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611
Mailing Address - Country:US
Mailing Address - Phone:510-418-3109
Mailing Address - Fax:
Practice Address - Street 1:3871 HOWE ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611
Practice Address - Country:US
Practice Address - Phone:510-418-3109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-24
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY27600103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist