Healthcare Provider Details

I. General information

NPI: 1184459018
Provider Name (Legal Business Name): MINDLOFT FAMILY THERAPY INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2024
Last Update Date: 01/06/2026
Certification Date: 01/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W CHAPMAN AVE STE 200
ORANGE CA
92866-1418
US

IV. Provider business mailing address

PO BOX 3340
TUSTIN CA
92781-3340
US

V. Phone/Fax

Practice location:
  • Phone: 855-750-5010
  • Fax:
Mailing address:
  • Phone: 949-569-9226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

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