Provider Demographics
NPI:1073738225
Name:WYMAN, ROBERTA G (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTA
Middle Name:G
Last Name:WYMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17011 BEACH BLVD
Mailing Address - Street 2:SUITE 900
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-5946
Mailing Address - Country:US
Mailing Address - Phone:714-842-8680
Mailing Address - Fax:714-375-6699
Practice Address - Street 1:16581 SELL CIR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-3298
Practice Address - Country:US
Practice Address - Phone:714-842-8680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12487103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY12487OtherCALIF LIC