MEDICARE: DEREK K. WANGBERG A PSYCHOLOGICAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY21059	CA

General Provider Information

NPI Number	:	1659518835
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEREK K. WANGBERG A PSYCHOLOGICAL CORPORATION

Provider Business Mailing Address
First Line	:	211 INDIANAPOLIS AVE
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92648-4322
Country	:	US
Telephone Number	:	714-369-5117
Fax Number	:

Provider Business Practice Location Address
First Line	:	211 INDIANAPOLIS AVE
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92648-4322
Country	:	US
Telephone Number	:	714-369-5117
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL PSYCHOLOGIST
Name	:	DR. DEREK KEVIN WANGBERG
Credential	:	PSY.D.
Telephone Number	:	714-369-5117

Provider Enumeration Date	:	01/09/2009
Last Update Date	:	01/09/2009

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