Healthcare Provider Details

I. General information

NPI: 1871946103
Provider Name (Legal Business Name): VANESSA WYCHE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2016
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1627 S HARGRAVE ST
BANNING CA
92220-6169
US

IV. Provider business mailing address

1627 S HARGRAVE ST
BANNING CA
92220-6169
US

V. Phone/Fax

Practice location:
  • Phone: 951-922-7826
  • Fax:
Mailing address:
  • Phone: 951-922-7826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number91020
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: