1679596282 NPI number — WENDI MAURER PH.D.

Table of content: WENDI MAURER PH.D. (NPI 1679596282)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679596282 NPI number — WENDI MAURER PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAURER
Provider First Name:
WENDI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679596282
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8813 VILLA LA JOLLA DR
Provider Second Line Business Mailing Address:
STE 2002
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-1927
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-491-3459
Provider Business Mailing Address Fax Number:
858-453-8634

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3252 HOLIDAY CT
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
LA JOLLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92037-0027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-491-3459
Provider Business Practice Location Address Fax Number:
858-453-8634
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY 12694 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PSY126940 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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