Provider Demographics
NPI:1891823944
Name:WAKEFIELD, CYNTHIA J
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:J
Last Name:WAKEFIELD
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 1:2180 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-4513
Mailing Address - Country:US
Mailing Address - Phone:805-461-6060
Mailing Address - Fax:805-461-6061
Practice Address - Street 1:1244 PINE ST
Practice Address - Street 2:STE 214
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-7241
Practice Address - Country:US
Practice Address - Phone:805-461-6060
Practice Address - Fax:805-461-6061
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CALCSW848051041C0700X
CAMSW390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMED MENTOROtherCSHCENTERSAC