Provider Demographics
NPI:1528126703
Name:WIELENGA, WILTON JAN (LCSW)
Entity type:Individual
Prefix:MR
First Name:WILTON
Middle Name:JAN
Last Name:WIELENGA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 W HAMMER LANE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-2900
Mailing Address - Country:US
Mailing Address - Phone:209-477-9180
Mailing Address - Fax:209-952-8520
Practice Address - Street 1:1755 W HAMMER LANE
Practice Address - Street 2:SUITE 1
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-2900
Practice Address - Country:US
Practice Address - Phone:209-477-9180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 56811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ79444ZMedicare ID - Type Unspecified