=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134558356
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN EDWARD WAINWRIGHT MFT INTERN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2013
-----------------------------------------------------
Last Update Date | 04/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 13TH ST. PACIFIC GROVE
-----------------------------------------------------
City | PACIFIC GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93950-9395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-519-5589
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 205 13TH ST. PACIFIC GROVE
-----------------------------------------------------
City | PACIFIC GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93950-6310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-519-5589
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 110402
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------