Provider Demographics
NPI:1194980250
Name:WIGGINS, KENNETH
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:WIGGINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7850 VISTA HILL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2717
Mailing Address - Country:US
Mailing Address - Phone:858-836-8675
Mailing Address - Fax:
Practice Address - Street 1:328 SEEDLING WAY
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-6544
Practice Address - Country:US
Practice Address - Phone:858-836-8675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA370069QN101YA0400X
CALCSW1301431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3719Medicaid