Provider Demographics
NPI:1427308485
Name:WOLD, MICHELLE CLAIRE (PSYD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:CLAIRE
Last Name:WOLD
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 MARIPOSA ST STE 312
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94107-2367
Mailing Address - Country:US
Mailing Address - Phone:415-806-9489
Mailing Address - Fax:
Practice Address - Street 1:810 COLLEGE AVE STE 7
Practice Address - Street 2:
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-2532
Practice Address - Country:US
Practice Address - Phone:415-758-2830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
1-12-12595103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist