Provider Demographics
NPI:1356950414
Name:KIRK-SCALISE, WENDY (MFT)
Entity type:Individual
Prefix:DR
First Name:WENDY
Middle Name:
Last Name:KIRK-SCALISE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:DR
Other - First Name:WENDY
Other - Middle Name:
Other - Last Name:KIRK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD,MFT
Mailing Address - Street 1:552 WISTERIA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2426
Mailing Address - Country:US
Mailing Address - Phone:415-453-6139
Mailing Address - Fax:
Practice Address - Street 1:711 D ST STE 201
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3704
Practice Address - Country:US
Practice Address - Phone:415-453-6139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-24
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT15940106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty