Healthcare Provider Details

I. General information

NPI: 1346891934
Provider Name (Legal Business Name): STEPHANIE WOODEN MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE WYSOCKI

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 01/29/2026
Certification Date: 01/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 OTAY MESA RD
SAN YSIDRO CA
92173-1685
US

IV. Provider business mailing address

4350 OTAY MESA RD
SAN YSIDRO CA
92173-1685
US

V. Phone/Fax

Practice location:
  • Phone: 619-428-2352
  • Fax:
Mailing address:
  • Phone: 619-428-2352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number117604
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: