Provider Demographics
NPI:1558419994
Name:BROTHERS, WANDA L (MFT, SEP)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:L
Last Name:BROTHERS
Suffix:
Gender:F
Credentials:MFT, SEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 10TH ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-3416
Mailing Address - Country:US
Mailing Address - Phone:619-437-1465
Mailing Address - Fax:
Practice Address - Street 1:1224 10TH ST
Practice Address - Street 2:SUITE 206
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-3416
Practice Address - Country:US
Practice Address - Phone:619-437-1465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 43341106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist