Provider Demographics
NPI:1639831613
Name:WIMBERLY, JOHN EDWARD SR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:WIMBERLY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3939 ATLANTIC AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3535
Mailing Address - Country:US
Mailing Address - Phone:562-473-0827
Mailing Address - Fax:562-473-0825
Practice Address - Street 1:3939 ATLANTIC AVE STE 102
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3535
Practice Address - Country:US
Practice Address - Phone:562-473-0827
Practice Address - Fax:562-473-0825
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)