Provider Demographics
NPI:1700911666
Name:WANGBERG, DEREK (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:WANGBERG
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11401 BLOOMFIELD
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650
Mailing Address - Country:US
Mailing Address - Phone:714-369-5117
Mailing Address - Fax:949-429-7793
Practice Address - Street 1:11401 BLOOMFIELD
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650
Practice Address - Country:US
Practice Address - Phone:714-569-5117
Practice Address - Fax:949-429-7791
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 21059103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP21059Medicare PIN