Provider Demographics
NPI:1134470701
Name:WIENS, KATHRYN MAY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:MAY
Last Name:WIENS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 IMPERIAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-7638
Mailing Address - Country:US
Mailing Address - Phone:619-233-8500
Mailing Address - Fax:
Practice Address - Street 1:3517 CAMINO DEL RIO S STE 302
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4029
Practice Address - Country:US
Practice Address - Phone:619-996-3195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 103T00000X
CA27115103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103T00000XBehavioral Health & Social Service ProvidersPsychologist