Provider Demographics
NPI:1497528004
Name:WIEDNER, ELLEN KATHLEEN
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:KATHLEEN
Last Name:WIEDNER
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 1:37143 SANTA ROSA GLEN DR
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-3263
Mailing Address - Country:US
Mailing Address - Phone:310-357-4680
Mailing Address - Fax:
Practice Address - Street 1:37143 SANTA ROSA GLEN DR
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-3263
Practice Address - Country:US
Practice Address - Phone:310-357-4680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14935101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health