MEDICARE: MS. LYNNETTE MARIE WILHARDT LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCS16597	CA

General Provider Information

NPI Number	:	1114228905
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LYNNETTE MARIE WILHARDT LCSW

Provider Business Mailing Address
First Line	:	PO BOX 5245
Second Line	:
City	:	BALBOA ISLAND
State	:	CA
Zip	:	92662-5245
Country	:	US
Telephone Number	:	714-417-1171
Fax Number	:

Provider Business Practice Location Address
First Line	:	151 KALMUS DR STE C245
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92626-7954
Country	:	US
Telephone Number	:	714-417-1171
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2010
Last Update Date	:	11/09/2010

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