Provider Demographics
NPI:1871946103
Name:WYCHE, VANESSA (LCSW)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:WYCHE
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 1:1627 S HARGRAVE ST
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-6169
Mailing Address - Country:US
Mailing Address - Phone:951-922-7826
Mailing Address - Fax:
Practice Address - Street 1:1627 S HARGRAVE ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-6169
Practice Address - Country:US
Practice Address - Phone:951-922-7826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA910201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical