Provider Demographics
NPI:1194840660
Name:WEISSBEIN MACKEN, CYNTHIA LYNN (PSYD)
Entity type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:LYNN
Last Name:WEISSBEIN MACKEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2133 CALISTOGA RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-8417
Mailing Address - Country:US
Mailing Address - Phone:707-484-7979
Mailing Address - Fax:707-566-2115
Practice Address - Street 1:1821 4TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-3202
Practice Address - Country:US
Practice Address - Phone:707-484-7979
Practice Address - Fax:707-566-2115
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14465103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL144652Medicare ID - Type UnspecifiedMEDICARE PROVIDER