Provider Demographics
NPI:1174645642
Name:WEIDNER, TIMOTHY J (MFT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:J
Last Name:WEIDNER
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3846 23RD ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-3332
Mailing Address - Country:US
Mailing Address - Phone:415-509-6295
Mailing Address - Fax:
Practice Address - Street 1:14651 S BASCOM AVE
Practice Address - Street 2:STE 230
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-2014
Practice Address - Country:US
Practice Address - Phone:415-509-6295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41813106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist