Provider Demographics
NPI:1871152132
Name:WAX, CONNIE LEE (LCSW)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:LEE
Last Name:WAX
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5182 KATELLA
Mailing Address - Street 2:SUITE 206
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720
Mailing Address - Country:US
Mailing Address - Phone:714-300-3163
Mailing Address - Fax:
Practice Address - Street 1:5182 KATELLA
Practice Address - Street 2:SUITE 206
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720
Practice Address - Country:US
Practice Address - Phone:714-300-3163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW274301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical