Provider Demographics
NPI:1124052196
Name:WOLLESON, CAROL A (MFT)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:A
Last Name:WOLLESON
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:758 KINGSTON AVE
Mailing Address - Street 2:NO 202
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-4402
Mailing Address - Country:US
Mailing Address - Phone:510-420-1366
Mailing Address - Fax:510-653-8167
Practice Address - Street 1:2960 CAMINO DIABLO
Practice Address - Street 2:SUITE 200
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94597-3988
Practice Address - Country:US
Practice Address - Phone:510-420-1366
Practice Address - Fax:510-653-8167
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:2006-08-30
Deactivation Code:
Reactivation Date:2007-01-18
Provider Licenses
StateLicense IDTaxonomies
CAMFC21992106H00000X
ORT0196106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist