Healthcare Provider Details

I. General information

NPI: 1831715473
Provider Name (Legal Business Name): WISDOM WELLNESS PSYCHOTHERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 S. LEMON AVE #4028
WALNUT CA
91789
US

IV. Provider business mailing address

340 S. LEMON AVE #4028
WALNUT CA
91789
US

V. Phone/Fax

Practice location:
  • Phone: 916-546-5228
  • Fax:
Mailing address:
  • Phone: 916-546-5228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. CHASSITY ANGENY-SHOWALTER
Title or Position: OWNER/CEO
Credential: PSYD
Phone: 916-546-5228