Provider Demographics
NPI:1184989105
Name:NEW MINDFUL LIFE A PROFESSIONAL PSYCHOLOGICAL CORPORATION
Entity type:Organization
Organization Name:NEW MINDFUL LIFE A PROFESSIONAL PSYCHOLOGICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ROCHELLE
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:VOTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:619-261-8510
Mailing Address - Street 1:PO BOX 34494
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-4494
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2120 W WASHINGTON ST STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-2054
Practice Address - Country:US
Practice Address - Phone:619-261-8510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-05
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22284103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty