Provider Demographics
NPI:1184292088
Name:WOLBERT, SUSAN MARIE
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:WOLBERT
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 1:40925 COUNTY CENTER DR
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-6054
Mailing Address - Country:US
Mailing Address - Phone:951-600-6410
Mailing Address - Fax:
Practice Address - Street 1:40925 COUNTY CENTER DR
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-6054
Practice Address - Country:US
Practice Address - Phone:951-600-6410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1297330318101YA0400X
CAVQGWOSLHPKFEIYNZ172V00000X, 175T00000X
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker