Healthcare Provider Details

I. General information

NPI: 1235680059
Provider Name (Legal Business Name): LUCIE WANBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 EMPIRE ST
FAIRFIELD CA
94533
US

IV. Provider business mailing address

801 EMPIRE ST
FAIRFIELD CA
94533-5702
US

V. Phone/Fax

Practice location:
  • Phone: 707-425-5744
  • Fax: 707-425-5162
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP16109
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: