Healthcare Provider Details

I. General information

NPI: 1720800667
Provider Name (Legal Business Name): MIND SPACE MENTAL HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2024
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31852 COAST HWY STE 400
LAGUNA BEACH CA
92651-6767
US

IV. Provider business mailing address

31852 COAST HWY STE 400
LAGUNA BEACH CA
92651-6767
US

V. Phone/Fax

Practice location:
  • Phone: 949-689-9754
  • Fax:
Mailing address:
  • Phone: 949-689-9754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES TUAN-TU SONG NGUYEN
Title or Position: DOCTOR/CEO
Credential: MD
Phone: 949-689-9754