Healthcare Provider Details

I. General information

NPI: 1215259783
Provider Name (Legal Business Name): LETICIA WIESNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2010
Last Update Date: 02/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3270 KERNER BLVD
SAN RAFAEL CA
94901-4840
US

IV. Provider business mailing address

17671 TRENTON DR
CASTRO VALLEY CA
94546-1512
US

V. Phone/Fax

Practice location:
  • Phone: 415-457-6964
  • Fax: 415-456-1508
Mailing address:
  • Phone: 510-728-0361
  • Fax: 415-456-1508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: