Provider Demographics
NPI:1902899354
Name:WILCKENS-GJATA, PAOLA ALESSANDRA (LCSW)
Entity Type:Individual
Prefix:
First Name:PAOLA
Middle Name:ALESSANDRA
Last Name:WILCKENS-GJATA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2541 STATE ST
Mailing Address - Street 2:SUITE 115
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1678
Mailing Address - Country:US
Mailing Address - Phone:760-535-1847
Mailing Address - Fax:
Practice Address - Street 1:2541 STATE ST
Practice Address - Street 2:SUITE 115
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1678
Practice Address - Country:US
Practice Address - Phone:760-535-1847
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 211441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACSW211440Medicaid
CACSW211440Medicaid