Provider Demographics
NPI:1104997691
Name:WASIELEWSKI, RALENE MATTHIAS (LMFT)
Entity type:Individual
Prefix:MRS
First Name:RALENE
Middle Name:MATTHIAS
Last Name:WASIELEWSKI
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2176 ARLEEN WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95130-1901
Mailing Address - Country:US
Mailing Address - Phone:408-207-8291
Mailing Address - Fax:
Practice Address - Street 1:200 S SANTA CRUZ AVE STE 200
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95030-6743
Practice Address - Country:US
Practice Address - Phone:408-207-8291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37923106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist