Healthcare Provider Details

I. General information

NPI: 1730664061
Provider Name (Legal Business Name): WESLEY EARL HENDRIKSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

137 N COTTONWOOD ST
WOODLAND CA
95695-6646
US

IV. Provider business mailing address

137 N COTTONWOOD ST
WOODLAND CA
95695-6646
US

V. Phone/Fax

Practice location:
  • Phone: 530-666-8630
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT37224
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: