Provider Demographics
NPI:1497913560
Name:MOUR, WENDY REYNOSO (MSW)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:REYNOSO
Last Name:MOUR
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 S OAK KNOLL AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-2611
Mailing Address - Country:US
Mailing Address - Phone:626-993-3000
Mailing Address - Fax:
Practice Address - Street 1:118 S OAK KNOLL AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-2611
Practice Address - Country:US
Practice Address - Phone:626-993-3000
Practice Address - Fax:323-795-7080
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA32223101YM0800X
CALCSW686681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health