Provider Demographics
NPI:1740812213
Name:VAITAYAVIJIT, NUTTACHA (LMFT)
Entity type:Individual
Prefix:MRS
First Name:NUTTACHA
Middle Name:
Last Name:VAITAYAVIJIT
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 E GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5413
Mailing Address - Country:US
Mailing Address - Phone:951-205-5456
Mailing Address - Fax:
Practice Address - Street 1:755 E GILBERT ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-7200
Practice Address - Country:US
Practice Address - Phone:909-387-7792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA115808106H00000X
CA131167106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist