Provider Demographics
NPI:1659518835
Name:DEREK K. WANGBERG A PSYCHOLOGICAL CORPORATION
Entity Type:Organization
Organization Name:DEREK K. WANGBERG A PSYCHOLOGICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:WANGBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:714-369-5117
Mailing Address - Street 1:211 INDIANAPOLIS AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-4322
Mailing Address - Country:US
Mailing Address - Phone:714-369-5117
Mailing Address - Fax:
Practice Address - Street 1:211 INDIANAPOLIS AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-4322
Practice Address - Country:US
Practice Address - Phone:714-369-5117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY21059103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP21059Medicare PIN