Basic Information
| Provider Information | |||||||||
| NPI: | 1194973669 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONKLIN | ||||||||
| FirstName: | WESLEY | ||||||||
| MiddleName: | W | ||||||||
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| Mailing Information | |||||||||
| Address1: | 309 E MOUNTAIN VIEW ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BARSTOW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923112814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602560376 | ||||||||
| FaxNumber: | 7602660377 | ||||||||
| Practice Location | |||||||||
| Address1: | 309 E MOUNTAIN VIEW ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BARSTOW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923112814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602560376 | ||||||||
| FaxNumber: | 7602660377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2008 | ||||||||
| LastUpdateDate: | 09/08/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.