Provider Demographics
NPI:1225348832
Name:MINDWAVES PSYCHOLOGICAL SERVICES, INC.
Entity Type:Organization
Organization Name:MINDWAVES PSYCHOLOGICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:TERRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, PHD
Authorized Official - Phone:626-331-6170
Mailing Address - Street 1:4335 VAN NUYS BLVD
Mailing Address - Street 2:184
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-3727
Mailing Address - Country:US
Mailing Address - Phone:626-331-6170
Mailing Address - Fax:
Practice Address - Street 1:4335 VAN NUYS BLVD
Practice Address - Street 2:184
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-3727
Practice Address - Country:US
Practice Address - Phone:626-331-6170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17840103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty