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General NPI Number Information
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NPI Number | 1215534565
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Entity Type | Organization
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Legal Business Name | DR. WIYATTA PSYCHOLOGY CORPORATION
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Dates
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Enumeration Date | 10/08/2020
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Last Update Date | 10/08/2020
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Provider Practice Location Address
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Address Line | 10153 1/2 RIVERSIDE DR STE 440
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City | TOLUCA LAKE
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State | CA
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Zip | 91602-2561
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Country | US
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Telephone | 310-621-3673
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Fax |
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Provider Business Mailing Address
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Address Line | 10153 1/2 RIVERSIDE DR STE 440
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City | TOLUCA LAKE
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State | CA
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Zip | 91602-2561
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Country | US
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Telephone | 310-621-3673
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. WIYATTA FAHNBULLEH
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Credential | PSYD
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Telephone | 310-621-3673
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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