Provider Demographics
NPI:1669012787
Name:GRICELDA FRAGOSO PSYD A PROFESSIONAL PSYCHOLOGY CORPORATION
Entity Type:Organization
Organization Name:GRICELDA FRAGOSO PSYD A PROFESSIONAL PSYCHOLOGY CORPORATION
Other - Org Name:MIND BODY SOUL PSYCHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GRICELDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAGOSO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:760-487-8488
Mailing Address - Street 1:1398 NIGHTSHADE RD
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92011-3500
Mailing Address - Country:US
Mailing Address - Phone:858-371-1865
Mailing Address - Fax:760-557-2048
Practice Address - Street 1:721 N VULCAN AVE STE 209
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2191
Practice Address - Country:US
Practice Address - Phone:604-878-4887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-07
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty