Healthcare Provider Details

I. General information

NPI: 1003697913
Provider Name (Legal Business Name): MADELINE WEERTS AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2023
Last Update Date: 10/09/2023
Certification Date: 10/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8600 LA MESA BLVD STE B
LA MESA CA
91942-9572
US

IV. Provider business mailing address

8600 LA MESA BLVD STE B
LA MESA CA
91942-9572
US

V. Phone/Fax

Practice location:
  • Phone: 619-733-6414
  • Fax:
Mailing address:
  • Phone: 619-733-6414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT136368
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: