Basic Information
| Provider Information | |||||||||
| NPI: | 1437365491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HIGDON | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAY | ||||||||
| OtherFirstName: | WENDY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2120 THIBODO COURT | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920817901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582791223 | ||||||||
| FaxNumber: | 7605974880 | ||||||||
| Practice Location | |||||||||
| Address1: | 2120 THIBODO COURT | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920817901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582791223 | ||||||||
| FaxNumber: | 7605974880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 06/13/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC47745 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.