Provider Demographics
NPI:1619376621
Name:WISHART, WENDY (MA, MFTI#73685)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:
Last Name:WISHART
Suffix:
Gender:F
Credentials:MA, MFTI#73685
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 CROMART CT
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-3240
Mailing Address - Country:US
Mailing Address - Phone:415-889-3205
Mailing Address - Fax:
Practice Address - Street 1:555 NORTHGATE DR STE 100
Practice Address - Street 2:FAMILY SERVICES AGENCY OF MARIN
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-3696
Practice Address - Country:US
Practice Address - Phone:415-889-3205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73685101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health