Healthcare Provider Details

I. General information

NPI: 1629566245
Provider Name (Legal Business Name): I-TING WANG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 CAMINO MIRA COSTA SAN CLEMENTE SUITE T
SAN CLEMENTE CA
92672
US

IV. Provider business mailing address

18012 COWAN STE 200
IRVINE CA
92614-6823
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-4455
  • Fax:
Mailing address:
  • Phone: 949-864-6857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number120971
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: