Basic Information
Provider Information | |||||||||
NPI: | 1417103516 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEGLEY | ||||||||
FirstName: | REBECCA | ||||||||
MiddleName: | LYNNE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 206 S CALIFORNIA AVE | ||||||||
Address2: | C/O MOMENTUM FOR MENTAL HEALTH/LA SELVA GROUP | ||||||||
City: | PALO ALTO | ||||||||
State: | CA | ||||||||
PostalCode: | 943061618 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6506178340 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1608 HOPE DR | ||||||||
Address2: | #214 | ||||||||
City: | SANTA CLARA | ||||||||
State: | CA | ||||||||
PostalCode: | 950541726 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6503995509 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/08/2008 | ||||||||
LastUpdateDate: | 09/19/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
No ID Information.