Healthcare Provider Details

I. General information

NPI: 1548878853
Provider Name (Legal Business Name): JOHN WUNDERLEY MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2020
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5311 D ST
SACRAMENTO CA
95819-3011
US

IV. Provider business mailing address

5311 D ST
SACRAMENTO CA
95819-3011
US

V. Phone/Fax

Practice location:
  • Phone: 831-521-9716
  • Fax:
Mailing address:
  • Phone: 831-521-9716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: