Provider Demographics
NPI:1518496124
Name:WENDEROTH, CHRISTINE ROSE (LPCC)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:ROSE
Last Name:WENDEROTH
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:ROSE
Other - Last Name:MORTENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1209 619 CUDDY CANYON RD
Mailing Address - Street 2:
Mailing Address - City:LEBEC
Mailing Address - State:CA
Mailing Address - Zip Code:93243
Mailing Address - Country:US
Mailing Address - Phone:410-428-0666
Mailing Address - Fax:661-868-6752
Practice Address - Street 1:619 CUDDY CANYON RD
Practice Address - Street 2:
Practice Address - City:LEBEC
Practice Address - State:CA
Practice Address - Zip Code:93243
Practice Address - Country:US
Practice Address - Phone:410-428-0666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA9667101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator