Healthcare Provider Details

I. General information

NPI: 1578816849
Provider Name (Legal Business Name): ILANA S WASSERMAN MFT, LEP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2012
Last Update Date: 10/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 W ORANGEWOOD AVE STE. 101
ORANGE CA
92868-2004
US

IV. Provider business mailing address

1745 W ORANGEWOOD AVE STE. 101
ORANGE CA
92868-2004
US

V. Phone/Fax

Practice location:
  • Phone: 714-856-8333
  • Fax: 714-936-7720
Mailing address:
  • Phone: 714-856-8333
  • Fax: 714-936-7720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number2783
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number40707
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: