Provider Demographics
NPI:1447745823
Name:WOLLENBERG, MIRA LOUISE
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:LOUISE
Last Name:WOLLENBERG
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 1:6 HUNTLEIGH RD
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94611-3320
Mailing Address - Country:US
Mailing Address - Phone:510-285-7327
Mailing Address - Fax:
Practice Address - Street 1:1025 ATLANTIC AVE STE 101
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1188
Practice Address - Country:US
Practice Address - Phone:510-268-8120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst