Provider Demographics
NPI:1487268462
Name:WATHERN, PAUL C
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:C
Last Name:WATHERN
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 1:2980 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-1599
Mailing Address - Country:US
Mailing Address - Phone:619-301-9340
Mailing Address - Fax:
Practice Address - Street 1:835 25TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2738
Practice Address - Country:US
Practice Address - Phone:619-239-9691
Practice Address - Fax:619-239-0909
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-07
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR139800620101YA0400X
CAR1393800620101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)