Provider Demographics
NPI:1760990592
Name:DENNIS, MEREDITH LEIGH (PHD)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:LEIGH
Last Name:DENNIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 W LA VETA AVE STE 470
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4233
Mailing Address - Country:US
Mailing Address - Phone:714-509-4418
Mailing Address - Fax:
Practice Address - Street 1:1201 W LA VETA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4203
Practice Address - Country:US
Practice Address - Phone:714-509-4418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-15
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-16-27302106S00000X
CA32213103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA32213OtherCALIFORNIA BOARD OF PSYCHOLOGY
CARBT-16-27302OtherREGISTERED BEHAVIOR TECHNICIAN