Healthcare Provider Details

I. General information

NPI: 1518496124
Provider Name (Legal Business Name): CHRISTINE ROSE WENDEROTH LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTINE ROSE MORTENSEN

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 CUDDY CANYON RD
LEBEC CA
93243
US

IV. Provider business mailing address

P.O. BOX 1209 619 CUDDY CANYON RD
LEBEC CA
93243
US

V. Phone/Fax

Practice location:
  • Phone: 410-428-0666
  • Fax:
Mailing address:
  • Phone: 410-428-0666
  • Fax: 661-868-6752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9667
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: