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General NPI Number Information
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NPI Number | 1679176937
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Entity Type | Organization
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Legal Business Name | WANDERING COLLECTIVE LLC
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Dates
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Enumeration Date | 11/19/2020
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Last Update Date | 11/19/2020
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Provider Practice Location Address
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Address Line | 5960 S LAND PARK DR # 1194
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City | SACRAMENTO
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State | CA
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Zip | 95822-3313
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Country | US
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Telephone | 404-895-6416
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Fax |
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Provider Business Mailing Address
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Address Line | 2514 AMELIA EARHART AVE
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City | SACRAMENTO
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State | CA
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Zip | 95834-4003
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Country | US
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Telephone | 404-895-6416
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | EMILY FORTNEY
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Credential | PSY.D.
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Telephone | 404-895-6416
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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 |
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License Number State |
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