Provider Demographics
NPI:1518180330
Name:WEISER, PENNY HARRIET (PHD)
Entity Type:Individual
Prefix:DR
First Name:PENNY
Middle Name:HARRIET
Last Name:WEISER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 86489
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92138-6489
Mailing Address - Country:US
Mailing Address - Phone:619-615-9982
Mailing Address - Fax:619-426-1906
Practice Address - Street 1:815 3RD AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1307
Practice Address - Country:US
Practice Address - Phone:619-615-9982
Practice Address - Fax:619-426-1906
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 16796103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY167961Medicaid
CAPSY167961Medicaid