Healthcare Provider Details

I. General information

NPI: 1851167506
Provider Name (Legal Business Name): EMBODIED SELF PSYCHOLOGY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 12/04/2023
Certification Date: 12/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29578 SERENITY LN
MURRIETA CA
92563-5869
US

IV. Provider business mailing address

29578 SERENITY LN
MURRIETA CA
92563-5869
US

V. Phone/Fax

Practice location:
  • Phone: 619-361-1207
  • Fax: 760-452-5481
Mailing address:
  • Phone: 619-361-1207
  • Fax: 760-452-5481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name: BRENDA GOMEZ
Title or Position: CEO
Credential: PSY.D.
Phone: 619-361-1207