Provider Demographics
NPI:1114437787
Name:WAHLBERG, MIRKENA (AOD)
Entity Type:Individual
Prefix:MRS
First Name:MIRKENA
Middle Name:
Last Name:WAHLBERG
Suffix:
Gender:F
Credentials:AOD
Other - Prefix:
Other - First Name:MIRKENA
Other - Middle Name:
Other - Last Name:WAHLBERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1931 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-1105
Mailing Address - Country:US
Mailing Address - Phone:510-666-9552
Mailing Address - Fax:510-666-0987
Practice Address - Street 1:1931 CENTER ST
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1105
Practice Address - Country:US
Practice Address - Phone:510-666-9552
Practice Address - Fax:510-666-0987
Is Sole Proprietor?:No
Enumeration Date:2017-10-09
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00Other00