Healthcare Provider Details

I. General information

NPI: 1508101114
Provider Name (Legal Business Name): HEATHER MICHELLE WONDRA MFTI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2012
Last Update Date: 01/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N PACIFIC COAST HWY STE 200A
REDONDO BEACH CA
90277-7702
US

IV. Provider business mailing address

21520 PIONEER BLVD STE 203
HAWAIIAN GARDENS CA
90716-2601
US

V. Phone/Fax

Practice location:
  • Phone: 310-316-1610
  • Fax: 310-316-4209
Mailing address:
  • Phone: 855-462-7764
  • Fax: 562-924-4163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number68537
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: