Healthcare Provider Details

I. General information

NPI: 1336592047
Provider Name (Legal Business Name): WENDY WASSERMAN LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2016
Last Update Date: 07/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 SAINT MICHAELS DR STE 803
SANTA FE NM
87505-7643
US

IV. Provider business mailing address

2500 SAWMILL RD APT 1522
SANTA FE NM
87505-5692
US

V. Phone/Fax

Practice location:
  • Phone: 505-780-8108
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0168551
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: