Provider Demographics
NPI:1669808028
Name:WIECHERT, KAITLIN IRENE
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:IRENE
Last Name:WIECHERT
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 1:15160 CHEYENNE RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-3320
Mailing Address - Country:US
Mailing Address - Phone:760-985-4308
Mailing Address - Fax:760-256-5092
Practice Address - Street 1:473 EAST CARNEGIE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408
Practice Address - Country:US
Practice Address - Phone:949-385-2544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103427106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1891385258OtherNPPES