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General NPI Number Information
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NPI Number | 1215259783
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Entity Type | Individual
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Provider Name | LETICIA WIESNER
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Gender | Female
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Dates
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Enumeration Date | 02/24/2010
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Last Update Date | 02/24/2010
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Provider Practice Location Address
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Address Line | 3270 KERNER BLVD
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City | SAN RAFAEL
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State | CA
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Zip | 94901-4840
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Country | US
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Telephone | 415-457-6964
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Fax | 415-456-1508
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Provider Business Mailing Address
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Address Line | 17671 TRENTON DR
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City | CASTRO VALLEY
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State | CA
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Zip | 94546-1512
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Country | US
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Telephone | 510-728-0361
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Fax | 415-456-1508
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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