Provider Demographics
NPI:1871703629
Name:WEATHERFORD, VICKI LC (PHD)
Entity type:Individual
Prefix:DR
First Name:VICKI
Middle Name:LC
Last Name:WEATHERFORD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:220 CASCADE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94930-2133
Mailing Address - Country:US
Mailing Address - Phone:415-457-1312
Mailing Address - Fax:415-258-1733
Practice Address - Street 1:1010 SIR FRANCIS DRAKE BLVD STE 2
Practice Address - Street 2:
Practice Address - City:KENTFIELD
Practice Address - State:CA
Practice Address - Zip Code:94904-1444
Practice Address - Country:US
Practice Address - Phone:415-258-1723
Practice Address - Fax:415-258-1733
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPSY10416103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical