Healthcare Provider Details

I. General information

NPI: 1710579826
Provider Name (Legal Business Name): WAVEMIND INC, A PSYCHOLOGY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1849 SAWTELLE BLVD STE 610
LOS ANGELES CA
90025-7013
US

IV. Provider business mailing address

1849 SAWTELLE BLVD STE 610
LOS ANGELES CA
90025-7013
US

V. Phone/Fax

Practice location:
  • Phone: 914-275-5578
  • Fax:
Mailing address:
  • Phone: 914-275-5578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. DANIELLE CORNACCHIO
Title or Position: LICENSED PSYCHOLOGIST, OWNER
Credential: PHD
Phone: 914-275-5578