Healthcare Provider Details

I. General information

NPI: 1720625619
Provider Name (Legal Business Name): WENDY WYSONG MULLINS LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2019
Last Update Date: 03/01/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1632 E DIMONDALE DR
CARSON CA
90746-2915
US

IV. Provider business mailing address

1632 E DIMONDALE DR
CARSON CA
90746-2915
US

V. Phone/Fax

Practice location:
  • Phone: 310-218-3813
  • Fax:
Mailing address:
  • Phone: 310-218-3813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number111758
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number136744
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: