Healthcare Provider Details

I. General information

NPI: 1215534565
Provider Name (Legal Business Name): DR. WIYATTA PSYCHOLOGY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 10/08/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10153 1/2 RIVERSIDE DR STE 440
TOLUCA LAKE CA
91602-2561
US

IV. Provider business mailing address

10153 1/2 RIVERSIDE DR STE 440
TOLUCA LAKE CA
91602-2561
US

V. Phone/Fax

Practice location:
  • Phone: 310-621-3673
  • Fax:
Mailing address:
  • Phone: 310-621-3673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. WIYATTA FAHNBULLEH
Title or Position: PSYCHOLOGIST
Credential: PSYD
Phone: 310-621-3673