Healthcare Provider Details

I. General information

NPI: 1518175827
Provider Name (Legal Business Name): WENDY BOMBERG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 02/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 MILVIA ST
BERKELEY CA
94709-1934
US

IV. Provider business mailing address

1315 MILVIA ST
BERKELEY CA
94709-1934
US

V. Phone/Fax

Practice location:
  • Phone: 510-517-1256
  • Fax:
Mailing address:
  • Phone: 510-517-1256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS 24067
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: