Provider Demographics
NPI:1457801821
Name:WIGGINS, KENTE
Entity Type:Individual
Prefix:
First Name:KENTE
Middle Name:
Last Name:WIGGINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26081 MOCINE AVE
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94544-2923
Mailing Address - Country:US
Mailing Address - Phone:510-881-5921
Mailing Address - Fax:510-881-5925
Practice Address - Street 1:26081 MOCINE AVE
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544
Practice Address - Country:US
Practice Address - Phone:510-881-5921
Practice Address - Fax:510-881-5925
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)