Provider Demographics
NPI:1104949619
Name:SCHWERDTFEGER, SALLY ANN (PHD)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:ANN
Last Name:SCHWERDTFEGER
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 1:1761 HOTEL CIRCLE S.
Mailing Address - Street 2:STE 358
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108
Mailing Address - Country:US
Mailing Address - Phone:619-295-2600
Mailing Address - Fax:619-295-9096
Practice Address - Street 1:3368 2ND AVE
Practice Address - Street 2:STE D
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5666
Practice Address - Country:US
Practice Address - Phone:619-295-2600
Practice Address - Fax:619-295-9096
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 8348103TC0700X
CAPSY8348103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP 8348Medicare UPIN
CACP8348Medicare ID - Type Unspecified