Healthcare Provider Details

I. General information

NPI: 1639891682
Provider Name (Legal Business Name): BUENA VIBRA PSYCHOLOGICAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2022
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18000 STUDEBAKER RD STE 700
CERRITOS CA
90703-2684
US

IV. Provider business mailing address

18000 STUDEBAKER RD STE 700
CERRITOS CA
90703-2684
US

V. Phone/Fax

Practice location:
  • Phone: 310-864-0516
  • Fax: 323-364-5676
Mailing address:
  • Phone: 310-864-0516
  • Fax: 323-364-5676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: MILDRED ORTIZ
Title or Position: OWNER/CEO
Credential: PSY.D.
Phone: 310-864-0516