Provider Demographics
NPI:1033690235
Name:CONSCIOUS CULTURE PSYCHOLOGY CLINIC INC.
Entity Type:Organization
Organization Name:CONSCIOUS CULTURE PSYCHOLOGY CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:MIHECOBY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:626-658-4297
Mailing Address - Street 1:5800 S EASTERN AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:CA
Mailing Address - Zip Code:90040-4033
Mailing Address - Country:US
Mailing Address - Phone:626-658-4297
Mailing Address - Fax:
Practice Address - Street 1:5800 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90040-4016
Practice Address - Country:US
Practice Address - Phone:626-430-4521
Practice Address - Fax:626-498-1483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-24
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29218103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIN249ZMedicaid