Provider Demographics
NPI:1063543262
Name:MCWAIN, VICKI J (PHD)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:J
Last Name:MCWAIN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23121 WESTERN RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-4828
Mailing Address - Country:US
Mailing Address - Phone:909-854-3420
Mailing Address - Fax:
Practice Address - Street 1:17216 SLOVER AVE
Practice Address - Street 2:BUILDING L
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92337-7580
Practice Address - Country:US
Practice Address - Phone:909-854-3420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15326103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical