Provider Demographics
NPI:1033554795
Name:CORRILLO, GRETCHEN ANN WEISENBURGER (LMFT)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:ANN WEISENBURGER
Last Name:CORRILLO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:GRETCHEN
Other - Middle Name:ANN
Other - Last Name:WEISENBURGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:232 W. MAINSTREET
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780
Mailing Address - Country:US
Mailing Address - Phone:949-209-8858
Mailing Address - Fax:
Practice Address - Street 1:525 CABRILLO PARK DR STE 300
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-5017
Practice Address - Country:US
Practice Address - Phone:714-953-4455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-07
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFTI 70758101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health