Provider Demographics
NPI:1255941753
Name:DIRKS, MINDY PENZIAS (PHD)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:PENZIAS
Last Name:DIRKS
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 1:635 BRYANT ST # 7
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94301-2502
Mailing Address - Country:US
Mailing Address - Phone:408-893-5601
Mailing Address - Fax:
Practice Address - Street 1:635 BRYANT ST # 7
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94301-2502
Practice Address - Country:US
Practice Address - Phone:408-893-5601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-09
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29627103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical