Provider Demographics
NPI:1215390315
Name:WILDOMAR PSYCHOTHERAPY CENTER, INC.
Entity Type:Organization
Organization Name:WILDOMAR PSYCHOTHERAPY CENTER, INC.
Other - Org Name:WILDOMAR COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:951-279-5905
Mailing Address - Street 1:4117 PEARL ST.
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-2023
Mailing Address - Country:US
Mailing Address - Phone:951-279-5905
Mailing Address - Fax:951-279-5905
Practice Address - Street 1:33030 MISSION TRAIL
Practice Address - Street 2:
Practice Address - City:WILDOMAR
Practice Address - State:CA
Practice Address - Zip Code:92595-8423
Practice Address - Country:US
Practice Address - Phone:951-279-5905
Practice Address - Fax:951-279-5905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12109103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty