Provider Demographics
NPI:1588963573
Name:WEISHAUS, KENT A (LCSW)
Entity type:Individual
Prefix:MR
First Name:KENT
Middle Name:A
Last Name:WEISHAUS
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:PO BOX 723
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95402-0723
Mailing Address - Country:US
Mailing Address - Phone:951-288-5228
Mailing Address - Fax:951-257-0042
Practice Address - Street 1:54240 RIDGEVIEW DR
Practice Address - Street 2:SUITE 203
Practice Address - City:IDYLLWILD
Practice Address - State:CA
Practice Address - Zip Code:92549
Practice Address - Country:US
Practice Address - Phone:951-288-5228
Practice Address - Fax:951-257-0042
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-16
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 287721041C0700X
CALCSW287721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE