Provider Demographics
NPI:1346720562
Name:MINDSMITH, A PSYCHOLOGICAL PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MINDSMITH, A PSYCHOLOGICAL PROFESSIONAL CORPORATION
Other - Org Name:MINDSMITH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ANE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:619-378-7076
Mailing Address - Street 1:5575 LAKE PARK WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-1669
Mailing Address - Country:US
Mailing Address - Phone:619-378-7076
Mailing Address - Fax:619-303-4270
Practice Address - Street 1:2330 MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:CA
Practice Address - Zip Code:92065-2539
Practice Address - Country:US
Practice Address - Phone:619-376-7076
Practice Address - Fax:619-303-4270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17908103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA586347Medicaid