Provider Demographics
NPI:1023825478
Name:WILFONG, KASSANDRA JENNIENE
Entity type:Individual
Prefix:MISS
First Name:KASSANDRA
Middle Name:JENNIENE
Last Name:WILFONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 S KRAEMER BLVD UNIT 501
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-6112
Mailing Address - Country:US
Mailing Address - Phone:562-618-4330
Mailing Address - Fax:
Practice Address - Street 1:801 CORPORATE CENTER DR STE 210
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-2627
Practice Address - Country:US
Practice Address - Phone:909-618-0974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician