Basic Information
| Provider Information | |||||||||
| NPI: | 1033554795 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORRILLO | ||||||||
| FirstName: | GRETCHEN | ||||||||
| MiddleName: | ANN WEISENBURGER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEISENBURGER | ||||||||
| OtherFirstName: | GRETCHEN | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 232 W. MAINSTREET | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492098858 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 525 CABRILLO PARK DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927015017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149534455 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2013 | ||||||||
| LastUpdateDate: | 11/01/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MFTI 70758 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.