Healthcare Provider Details

I. General information

NPI: 1992298269
Provider Name (Legal Business Name): STEPHEN GUNNAR WASSATHER MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 06/12/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11434 B AVENUE
AUBURN CA
95603
US

IV. Provider business mailing address

101 CIRBY HILLS DR
ROSEVILLE CA
95678-4360
US

V. Phone/Fax

Practice location:
  • Phone: 530-889-7204
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number16640
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: