Healthcare Provider Details

I. General information

NPI: 1366717845
Provider Name (Legal Business Name): MINDFUL NEUROPSYCHOLOGY PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2012
Last Update Date: 03/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9255 TOWNE CENTRE DR STE 875
SAN DIEGO CA
92121-3064
US

IV. Provider business mailing address

9255 TOWNE CENTRE DR STE 875
SAN DIEGO CA
92121-3064
US

V. Phone/Fax

Practice location:
  • Phone: 858-888-2668
  • Fax: 858-455-5556
Mailing address:
  • Phone: 858-888-2668
  • Fax: 858-455-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20782
License Number StateCA

VIII. Authorized Official

Name: DR. AMANDA HAN
Title or Position: PRESIDENT
Credential: PSY.D.
Phone: 626-589-6155