Provider Demographics
NPI:1710579826
Name:WAVEMIND INC, A PSYCHOLOGY CORPORATION
Entity Type:Organization
Organization Name:WAVEMIND INC, A PSYCHOLOGY CORPORATION
Other - Org Name:WAVEMIND CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNACCHIO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:914-275-5578
Mailing Address - Street 1:1849 SAWTELLE BLVD STE 610
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-7013
Mailing Address - Country:US
Mailing Address - Phone:914-275-5578
Mailing Address - Fax:
Practice Address - Street 1:1849 SAWTELLE BLVD STE 610
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7013
Practice Address - Country:US
Practice Address - Phone:914-275-5578
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-09
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1528093820OtherDR. RONNIE LINDSEY BERGMAN
CA1396486023OtherDR. ANNA ALKOZEI