Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | PSY17421 | CA |
N | 103T00000X | Psychologist | PSY17421 | CA |
N | 103TB0200X | Cognitive & Behavioral Psychologist | PSY17421 | CA |
N | 103G00000X | Clinical Psychologist | PSY17421 | CA |
N | 103TC0700X | Clinical Psychologist | PSY17421 | CA |
N | 103TC1900X | Counseling Psychologist | PSY17421 | CA |
N | 103TF0200X | Forensic Psychologist | PSY17421 | CA |
N | 103TP2701X | Group Psychotherapist | PSY17421 | CA |
NPI | 1336191576 |
---|---|
Provider Name | Matthew Thomas Hennessy |
First Address | Sacramento, CA 95814-6414 |
Second Address | Atascadero, CA 93423-7001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/05/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
PSYCH | (02) |