Provider Demographics
NPI:1700099603
Name:WEGMAN, KRISTINE A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:A
Last Name:WEGMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 MAGNOLIA AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3123
Mailing Address - Country:US
Mailing Address - Phone:951-734-0525
Mailing Address - Fax:951-734-0063
Practice Address - Street 1:800 MAGNOLIA AVE
Practice Address - Street 2:STE 110
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3123
Practice Address - Country:US
Practice Address - Phone:951-734-0525
Practice Address - Fax:951-734-0063
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS23499101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health