Healthcare Provider Details

I. General information

NPI: 1144115643
Provider Name (Legal Business Name): MINDY LYNN JOHANNA SHIROMA PPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MINDY LYNN JOHANNA TAYET PPS

II. Dates (important events)

Enumeration Date: 06/12/2025
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 HIGHLAND AVE
DUARTE CA
91010-2523
US

IV. Provider business mailing address

1401 HIGHLAND AVE
DUARTE CA
91010-2523
US

V. Phone/Fax

Practice location:
  • Phone: 657-321-4000
  • Fax:
Mailing address:
  • Phone: 657-321-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number220103449
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: