Provider Demographics
NPI:1942800610
Name:WYETH, CHRISTINE IRENE I (LEP)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:IRENE
Last Name:WYETH
Suffix:I
Gender:F
Credentials:LEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 ORRELL DR
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-7019
Mailing Address - Country:US
Mailing Address - Phone:619-208-6358
Mailing Address - Fax:
Practice Address - Street 1:420 ORRELL DR
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-7019
Practice Address - Country:US
Practice Address - Phone:619-208-6358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3173103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool