Provider Demographics
NPI:1407382336
Name:HASELWOOD, WEDNESDAY (CATC-R)
Entity Type:Individual
Prefix:
First Name:WEDNESDAY
Middle Name:
Last Name:HASELWOOD
Suffix:
Gender:F
Credentials:CATC-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-4315
Mailing Address - Country:US
Mailing Address - Phone:310-519-8723
Mailing Address - Fax:310-519-9428
Practice Address - Street 1:270 W 14TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-4315
Practice Address - Country:US
Practice Address - Phone:310-519-8723
Practice Address - Fax:310-519-9428
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR#9228101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)