Provider Demographics
NPI:1235781543
Name:HANKS, WENDY NAOMI (SUDRC)
Entity Type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:NAOMI
Last Name:HANKS
Suffix:
Gender:F
Credentials:SUDRC
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:NAOMI
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SUDRC
Mailing Address - Street 1:371 E ST.
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910
Mailing Address - Country:US
Mailing Address - Phone:619-691-1045
Mailing Address - Fax:619-691-1491
Practice Address - Street 1:629 THIRD AVE STE C
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-5741
Practice Address - Country:US
Practice Address - Phone:619-691-1045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-16
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA11522101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA378542Medicaid