Provider Demographics
NPI:1376572438
Name:IMAGE TRANSFORMATION INSTITUTE
Entity Type:Organization
Organization Name:IMAGE TRANSFORMATION INSTITUTE
Other - Org Name:PSYCHTECH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:626-429-4945
Mailing Address - Street 1:1111 KLISH WAY
Mailing Address - Street 2:
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-2633
Mailing Address - Country:US
Mailing Address - Phone:626-676-5942
Mailing Address - Fax:858-724-3585
Practice Address - Street 1:1343 STRATFORD CT
Practice Address - Street 2:
Practice Address - City:DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92014-2327
Practice Address - Country:US
Practice Address - Phone:626-429-4945
Practice Address - Fax:858-724-3585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWCP20630AOtherPPIN FOR ROBERT MILLER CP
CAW19634Medicare ID - Type UnspecifiedPSYCHTECH GROUP ID NUMBER
CAQ65321Medicare UPIN