Basic Information
| Provider Information | |||||||||
| NPI: | 1679871552 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRASER DE AUGUSTINE | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MFT INTERN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11565 LAUREL CANYON | ||||||||
| Address2: | # 114 | ||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183615030 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11565 LAUREL CANYON | ||||||||
| Address2: | # 116 | ||||||||
| City: | MISSION HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183615030 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2011 | ||||||||
| LastUpdateDate: | 06/10/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.