Healthcare Provider Details

I. General information

NPI: 1336608769
Provider Name (Legal Business Name): KATHLEEN V WUNDERLING LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2019
Last Update Date: 03/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E DEL MAR BLVD STE 210
PASADENA CA
91105-2551
US

IV. Provider business mailing address

200 E DEL MAR BLVD STE 210
PASADENA CA
91105-2551
US

V. Phone/Fax

Practice location:
  • Phone: 310-560-8630
  • Fax:
Mailing address:
  • Phone: 310-560-8630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number112199
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: