Provider Demographics
NPI:1215534565
Name:DR. WIYATTA PSYCHOLOGY CORPORATION
Entity Type:Organization
Organization Name:DR. WIYATTA PSYCHOLOGY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WIYATTA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAHNBULLEH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:310-621-3673
Mailing Address - Street 1:10153 1/2 RIVERSIDE DR STE 440
Mailing Address - Street 2:
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91602-2561
Mailing Address - Country:US
Mailing Address - Phone:310-621-3673
Mailing Address - Fax:
Practice Address - Street 1:10153 1/2 RIVERSIDE DR STE 440
Practice Address - Street 2:
Practice Address - City:TOLUCA LAKE
Practice Address - State:CA
Practice Address - Zip Code:91602-2561
Practice Address - Country:US
Practice Address - Phone:310-621-3673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health