Healthcare Provider Details

I. General information

NPI: 1093415481
Provider Name (Legal Business Name): MYNDLOFT LICENSED CLINICAL SOCIAL WORKER PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 W CHAPMAN AVE STE 200
ORANGE CA
92866-1316
US

IV. Provider business mailing address

PO BOX 3340
TUSTIN CA
92781-3340
US

V. Phone/Fax

Practice location:
  • Phone: 855-750-5010
  • Fax: 619-354-1803
Mailing address:
  • Phone: 855-750-5010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DR. DALE ELERY WERNER
Title or Position: ADMINISTRATOR
Credential: PHD
Phone: 949-569-9226