Provider Demographics
NPI:1417004284
Name:VAN WIE, ANN KATHLEEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ANN
Middle Name:KATHLEEN
Last Name:VAN WIE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 SUNRISE AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4527
Mailing Address - Country:US
Mailing Address - Phone:916-786-3740
Mailing Address - Fax:916-773-0965
Practice Address - Street 1:775 SUNRISE AVE STE 120
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4527
Practice Address - Country:US
Practice Address - Phone:916-786-3740
Practice Address - Fax:916-773-0965
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALB0092831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMMM00063MMedicare ID - Type UnspecifiedMEDICARE ID