Healthcare Provider Details

I. General information

NPI: 1740217223
Provider Name (Legal Business Name): WESLEY DEAN THIESSEN L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 WOODWORTH AVE
CLOVIS CA
93612-1847
US

IV. Provider business mailing address

624 WOODWORTH AVE
CLOVIS CA
93612-1847
US

V. Phone/Fax

Practice location:
  • Phone: 559-297-6060
  • Fax: 559-297-6061
Mailing address:
  • Phone: 559-297-6060
  • Fax: 559-297-6061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS11767
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: