Basic Information
| Provider Information | |||||||||
| NPI: | 1053447383 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | WEICHING | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24575 VIA TONADA | ||||||||
| Address2: | |||||||||
| City: | LAKE FOREST | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926302027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9499105035 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5 MAREBLU STE 250 | ||||||||
| Address2: | |||||||||
| City: | ALISO VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926563014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9496436901 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC 44291 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.