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General NPI Number Information
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NPI Number | 1568670511
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Entity Type | Individual
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Provider Name | MARYANN WASILESKI PH.D.
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Gender | Female
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 08/14/2018
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Provider Practice Location Address
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Address Line | 1515 TRUEMPER ST
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City | JBSA LACKLAND
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State | TX
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Zip | 78236-5583
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Country | US
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Telephone | 210-671-2033
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Fax |
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Provider Business Mailing Address
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Address Line | 1515 TRUEMPER ST
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City | JBSA LACKLAND
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State | TX
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Zip | 78236-5583
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Country | US
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Telephone | 210-671-2033
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSYCH 7609
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License Number State | CA
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