Healthcare Provider Details

I. General information

NPI: 1992147680
Provider Name (Legal Business Name): ELIZABETH POULSEN WIEGAND PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2013
Last Update Date: 03/24/2025
Certification Date: 03/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3609 OCEAN RANCH BLVD STE 208&209
OCEANSIDE CA
92056-2698
US

IV. Provider business mailing address

3609 OCEAN RANCH BLVD STE 208&209
OCEANSIDE CA
92056-2698
US

V. Phone/Fax

Practice location:
  • Phone: 858-279-1223
  • Fax: 858-467-7161
Mailing address:
  • Phone: 858-279-1223
  • Fax: 858-467-7161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number29333
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: