Healthcare Provider Details

I. General information

NPI: 1679941983
Provider Name (Legal Business Name): MICHELE WILKENS PSYD A PSYCHOLOGICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2015
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 N MADISON AVE STE 601
PASADENA CA
91101-2047
US

IV. Provider business mailing address

65 N MADISON AVE STE 601
PASADENA CA
91101-2047
US

V. Phone/Fax

Practice location:
  • Phone: 323-375-8175
  • Fax:
Mailing address:
  • Phone: 323-375-8175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY25549
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHELE WILKENS
Title or Position: CLINICAL PSYCHOLOGIST
Credential:
Phone: 323-375-8175