Provider Demographics
NPI:1366711988
Name:CANIZALEZ, WILFREDO
Entity type:Individual
Prefix:
First Name:WILFREDO
Middle Name:
Last Name:CANIZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18566 CHATSWORTH ST
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-3142
Mailing Address - Country:US
Mailing Address - Phone:818-636-9364
Mailing Address - Fax:
Practice Address - Street 1:1200 WILSHIRE BLVD
Practice Address - Street 2:SUITE 500
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1908
Practice Address - Country:US
Practice Address - Phone:213-481-7464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF68770106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist