Provider Demographics
NPI:1215259783
Name:WIESNER, LETICIA
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:WIESNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17671 TRENTON DR
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-1512
Mailing Address - Country:US
Mailing Address - Phone:510-728-0361
Mailing Address - Fax:415-456-1508
Practice Address - Street 1:3270 KERNER BLVD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-4840
Practice Address - Country:US
Practice Address - Phone:415-457-6964
Practice Address - Fax:415-456-1508
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health