Provider Demographics
NPI:1699838813
Name:WAKEHAM, PAULINE JOAN (LCSW)
Entity type:Individual
Prefix:MS
First Name:PAULINE
Middle Name:JOAN
Last Name:WAKEHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:446 OLD COUNTY RD
Mailing Address - Street 2:UNIT 100-215
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-3270
Mailing Address - Country:US
Mailing Address - Phone:510-377-1082
Mailing Address - Fax:650-738-1040
Practice Address - Street 1:6239 COLLEGE AVE., SUITE 303
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618
Practice Address - Country:US
Practice Address - Phone:510-377-1082
Practice Address - Fax:650-738-1040
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS195281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABZ839ZMedicare UPIN
CAZZZ20412ZMedicare UPIN