Active NPI
Brenda Kay Wiederhold, PH.D.
- Clinical Psychologist
- La Jolla, CA
National Provider Identifier
1134745474
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- PSY16840
- Practice address
- Virtual Reality Medical Center
9834 Genesee Avenue, Suite 427
La Jolla, CA 92037 - Phone
- (858) 642-0267
- NPI assigned
- Jun 23, 2020
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | PSY16840 | CA | Primary |
Addresses
Primary practice location
Virtual Reality Medical Center
9834 Genesee Avenue, Suite 427
La Jolla, CA 92037
Mailing address
Virtual Reality Medical Center
6540 Lusk Boulevard, Suite C252
San Diego, CA 92121
Phone (858) 642-0267
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Dec 1, 2020 through Dec 1, 2026
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 16840 | CA | MD | Professional Counselor |
| PSY16840 | CA | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1592870400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1592870400000",
"number": "1134745474",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "VIRTUAL REALITY MEDICAL CENTER",
"address_2": "6540 LUSK BOULEVARD, SUITE C252",
"city": "SAN DIEGO",
"state": "CA",
"postal_code": "92121",
"telephone_number": "858-642-0267"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "VIRTUAL REALITY MEDICAL CENTER",
"address_2": "9834 GENESEE AVENUE, SUITE 427",
"city": "LA JOLLA",
"state": "CA",
"postal_code": "92037",
"telephone_number": "858-642-0267"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WIEDERHOLD",
"first_name": "BRENDA",
"middle_name": "KAY",
"name_prefix": "Dr.",
"credential": "PH.D.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2020-06-23",
"last_updated": "2020-06-23",
"certification_date": "2020-06-23",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "CA",
"license": "PSY16840",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in La Jolla, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 23, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.