Provider Demographics
NPI:1770705402
Name:WILBANKS, LINDA
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:WILBANKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 AVENUE OF THE ARTS
Mailing Address - Street 2:D119
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-1927
Mailing Address - Country:US
Mailing Address - Phone:714-319-9885
Mailing Address - Fax:
Practice Address - Street 1:660 BAKER ST
Practice Address - Street 2:211-E
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4428
Practice Address - Country:US
Practice Address - Phone:714-319-9885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41022106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist