Healthcare Provider Details

I. General information

NPI: 1538608179
Provider Name (Legal Business Name): CAITLIN MARIE VAN WORMER AMFT; APCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2017
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W CIVIC CENTER DR
SANTA ANA CA
92701-4515
US

IV. Provider business mailing address

P.O. BOX 28424
ANAHEIM CA
92809-2233
US

V. Phone/Fax

Practice location:
  • Phone: 714-480-6767
  • Fax:
Mailing address:
  • Phone: 714-850-8402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPCCI 3250
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFTI 95030
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: