Provider Demographics
NPI:1811047780
Name:WAKEFIELD, PHYLIS JANE (PHD)
Entity type:Individual
Prefix:DR
First Name:PHYLIS
Middle Name:JANE
Last Name:WAKEFIELD
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:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-0097
Mailing Address - Country:US
Mailing Address - Phone:707-222-6242
Mailing Address - Fax:
Practice Address - Street 1:1151 BROADWAY
Practice Address - Street 2:SUITE 202
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-7571
Practice Address - Country:US
Practice Address - Phone:770-722-2624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14649103TA0400X, 103TC0700X, 103TB0200X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy