Healthcare Provider Details

I. General information

NPI: 1003941915
Provider Name (Legal Business Name): WANDALYN LANE MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1585 S D ST 101
SAN BERNARDINO CA
92408-3257
US

IV. Provider business mailing address

1501 HUGHES WAY
LONG BEACH CA
90810-1876
US

V. Phone/Fax

Practice location:
  • Phone: 909-388-2222
  • Fax: 909-388-2220
Mailing address:
  • Phone: 310-221-6336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: