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NPI Code Detail

MEDICARE: BRIAN WEDDERBURN LCSW

MEDICARE: BRIAN WEDDERBURN LCSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1104100000XSocial WorkerASW72325CA

General Provider Information

NPI Number : 1255883435
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRIAN WEDDERBURN LCSW
Provider Business Mailing Address
First Line : 3322 CHANATE RD
Second Line :
City : SANTA ROSA
State : CA
Zip : 95404-1708
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 7165 BURTON AVE
Second Line :
City : ROHNERT PARK
State : CA
Zip : 94928-3316
Country : US
Telephone Number : 707-595-8866
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/04/2016
Last Update Date : 02/10/2022

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