Provider Demographics
NPI:1851167506
Name:EMBODIED SELF PSYCHOLOGY, INC.
Entity Type:Organization
Organization Name:EMBODIED SELF PSYCHOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:619-361-1207
Mailing Address - Street 1:29578 SERENITY LN
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-5869
Mailing Address - Country:US
Mailing Address - Phone:619-361-1207
Mailing Address - Fax:760-452-5481
Practice Address - Street 1:29578 SERENITY LN
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-5869
Practice Address - Country:US
Practice Address - Phone:619-361-1207
Practice Address - Fax:760-452-5481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1437787249OtherNPI1