Provider Demographics
NPI:1033355862
Name:WIEGAND, NATASHA ANNA (MFTI)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:ANNA
Last Name:WIEGAND
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 GLENBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-3810
Mailing Address - Country:US
Mailing Address - Phone:415-676-7660
Mailing Address - Fax:
Practice Address - Street 1:36 37TH AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-4405
Practice Address - Country:US
Practice Address - Phone:650-295-2160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-29
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51170106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA51170OtherSTATE OF CALIFORNIA BOARD OF BEHAVIORAL SCIENCES