Provider Demographics
NPI:1417568122
Name:WINTZ, ANNALISE
Entity Type:Individual
Prefix:
First Name:ANNALISE
Middle Name:
Last Name:WINTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13200 CROSSROADS PKWY N STE 300
Mailing Address - Street 2:
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91746-3459
Mailing Address - Country:US
Mailing Address - Phone:562-821-1491
Mailing Address - Fax:562-362-3137
Practice Address - Street 1:10800 PARAMOUNT BLVD STE 402
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3334
Practice Address - Country:US
Practice Address - Phone:562-821-1491
Practice Address - Fax:562-362-3137
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-14
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA390200000X
CA1085511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program