Basic Information
| Provider Information | |||||||||
| NPI: | 1639420748 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIPF | ||||||||
| FirstName: | THEADORA | ||||||||
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| Credential: | MFTI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 MENDOCINO DR | ||||||||
| Address2: | |||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954825315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074722922 | ||||||||
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| Practice Location | |||||||||
| Address1: | 631 S ORCHARD AVE | ||||||||
| Address2: | |||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074672010 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2012 | ||||||||
| LastUpdateDate: | 07/24/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 105413 | CA | N | Behavioral Health & Social Service Providers | Counselor | 225C00000X | 105413 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Counselor |
No ID Information.