Healthcare Provider Details

I. General information

NPI: 1376572438
Provider Name (Legal Business Name): IMAGE TRANSFORMATION INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1343 STRATFORD CT
DEL MAR CA
92014-2327
US

IV. Provider business mailing address

1111 KLISH WAY
DEL MAR CA
92014-2633
US

V. Phone/Fax

Practice location:
  • Phone: 626-429-4945
  • Fax: 858-724-3585
Mailing address:
  • Phone: 626-676-5942
  • Fax: 858-724-3585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT MICHAEL MILLER
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 626-429-4945