Provider Demographics
NPI:1508101114
Name:WONDRA, HEATHER MICHELLE (MFTI)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:MICHELLE
Last Name:WONDRA
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21520 PIONEER BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:HAWAIIAN GARDENS
Mailing Address - State:CA
Mailing Address - Zip Code:90716-2601
Mailing Address - Country:US
Mailing Address - Phone:855-462-7764
Mailing Address - Fax:562-924-4163
Practice Address - Street 1:901 N PACIFIC COAST HWY STE 200A
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-7702
Practice Address - Country:US
Practice Address - Phone:310-316-1610
Practice Address - Fax:310-316-4209
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-07
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68537106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist