Provider Demographics
NPI:1073866315
Name:WITHAM, WENDY ELISE (LMFT)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:ELISE
Last Name:WITHAM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 LYELL ST
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-4044
Mailing Address - Country:US
Mailing Address - Phone:650-948-4563
Mailing Address - Fax:
Practice Address - Street 1:140 LYELL ST
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94022-4044
Practice Address - Country:US
Practice Address - Phone:650-948-4563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC30634106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist