MEDICARE: THE VULNERABLE WOLF A PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1801619580
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE VULNERABLE WOLF A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	3911 CLEVELAND AVE UNIT 3541
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-3402
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3911 CLEVELAND AVE UNIT 3541
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-3402
Country	:	US
Telephone Number	:	619-752-0165
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	VANESSA TAN
Credential	:
Telephone Number	:	619-752-0165

Provider Enumeration Date	:	11/01/2024
Last Update Date	:	11/01/2024

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