Basic Information
| Provider Information | |||||||||
| NPI: | 1669808028 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIECHERT | ||||||||
| FirstName: | KAITLIN | ||||||||
| MiddleName: | IRENE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15160 CHEYENNE RD | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923073320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609854308 | ||||||||
| FaxNumber: | 7602565092 | ||||||||
| Practice Location | |||||||||
| Address1: | 473 EAST CARNEGIE DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493852544 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2013 | ||||||||
| LastUpdateDate: | 05/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 103427 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1891385258 | 01 | CA | NPPES | OTHER |