Provider Demographics
NPI:1326605965
Name:VON WUNSCH, INA PREM (AMFT)
Entity Type:Individual
Prefix:
First Name:INA
Middle Name:PREM
Last Name:VON WUNSCH
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 TAMAL VISTA DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-1645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3919 MACDONALD AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94805-2229
Practice Address - Country:US
Practice Address - Phone:510-233-7555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-20
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106887390200000X
CA128159106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program