Healthcare Provider Details

I. General information

NPI: 1942800610
Provider Name (Legal Business Name): CHRISTINE IRENE WYETH I LEP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 ORRELL DR
NATIONAL CITY CA
91950-7019
US

IV. Provider business mailing address

420 ORRELL DR
NATIONAL CITY CA
91950-7019
US

V. Phone/Fax

Practice location:
  • Phone: 619-208-6358
  • Fax:
Mailing address:
  • Phone: 619-208-6358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number3173
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: