=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578816849
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ILANA S WASSERMAN MFT, LEP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2012
-----------------------------------------------------
Last Update Date | 10/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1745 W ORANGEWOOD AVE STE. 101
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92868-2004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-856-8333
-----------------------------------------------------
Fax | 714-936-7720
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1745 W ORANGEWOOD AVE STE. 101
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92868-2004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-856-8333
-----------------------------------------------------
Fax | 714-936-7720
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 2783
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 40707
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------