Provider Demographics
NPI:1306147350
Name:REUSTLE, DODY J (PSYD)
Entity type:Individual
Prefix:DR
First Name:DODY
Middle Name:J
Last Name:REUSTLE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:711 JEFFERSON STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-5556
Mailing Address - Country:US
Mailing Address - Phone:707-342-3639
Mailing Address - Fax:707-427-2262
Practice Address - Street 1:711 JEFFERSON STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-5556
Practice Address - Country:US
Practice Address - Phone:707-342-3639
Practice Address - Fax:707-427-2262
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 23886103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical