Basic Information
| Provider Information | |||||||||
| NPI: | 1629566245 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANG | ||||||||
| FirstName: | I-TING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18012 COWAN STE 200 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926146823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9498646857 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3551 CAMINO MIRA COSTA SAN CLEMENTE | ||||||||
| Address2: | SUITE T | ||||||||
| City: | SAN CLEMENTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149534455 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2018 | ||||||||
| LastUpdateDate: | 01/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 120971 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.