Provider Demographics
NPI:1740653963
Name:VIENNA PSYCHOLOGICAL GROUP, INC.
Entity type:Organization
Organization Name:VIENNA PSYCHOLOGICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT & CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:VIENNA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:949-290-3947
Mailing Address - Street 1:464 E BONITA AVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3144
Mailing Address - Country:US
Mailing Address - Phone:626-709-3494
Mailing Address - Fax:
Practice Address - Street 1:464 E BONITA AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3144
Practice Address - Country:US
Practice Address - Phone:626-709-3494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-10
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X, 1041C0700X, 106H00000X
CA26945103TC0700X, 103TF0000X, 103TF0200X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamilyGroup - Single Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Single Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB261945Medicare PIN