Provider Demographics
NPI:1932719028
Name:WEDEKIND, DUSTIN JOHN
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:JOHN
Last Name:WEDEKIND
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 1:1021 FREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-8136
Mailing Address - Country:US
Mailing Address - Phone:530-541-2445
Mailing Address - Fax:
Practice Address - Street 1:1021 FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-8136
Practice Address - Country:US
Practice Address - Phone:530-541-2445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)