Provider Demographics
NPI:1043744055
Name:WILHELM, MAGDALENE ELISE (PCCI)
Entity Type:Individual
Prefix:
First Name:MAGDALENE
Middle Name:ELISE
Last Name:WILHELM
Suffix:
Gender:F
Credentials:PCCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 VIA ARBOLADA
Mailing Address - Street 2:UNIT 313
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042
Mailing Address - Country:US
Mailing Address - Phone:513-476-5359
Mailing Address - Fax:
Practice Address - Street 1:4210 VIA ARBOLADA
Practice Address - Street 2:UNIT 313
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90042
Practice Address - Country:US
Practice Address - Phone:513-476-5359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8516101YM0800X, 101YP2500X
CA2131101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health