Provider Demographics
NPI:1093415481
Name:MYNDLOFT LICENSED CLINICAL SOCIAL WORKER PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MYNDLOFT LICENSED CLINICAL SOCIAL WORKER PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:ELERY
Authorized Official - Last Name:WERNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:949-569-9226
Mailing Address - Street 1:PO BOX 3340
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92781-3340
Mailing Address - Country:US
Mailing Address - Phone:855-750-5010
Mailing Address - Fax:
Practice Address - Street 1:240 W CHAPMAN AVE STE 200
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-1316
Practice Address - Country:US
Practice Address - Phone:855-750-5010
Practice Address - Fax:619-354-1803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-06
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty