Provider Demographics
NPI:1306494950
Name:WEGNER, CORALIE (LEP 2804)
Entity type:Individual
Prefix:
First Name:CORALIE
Middle Name:
Last Name:WEGNER
Suffix:
Gender:F
Credentials:LEP 2804
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6960 DESTINY DR STE 112
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-2995
Mailing Address - Country:US
Mailing Address - Phone:916-296-0564
Mailing Address - Fax:
Practice Address - Street 1:6960 DESTINY DR STE 112
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-2995
Practice Address - Country:US
Practice Address - Phone:916-296-0564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2804103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool