Healthcare Provider Details

I. General information

NPI: 1922907443
Provider Name (Legal Business Name): MIRI ELIAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIRI KIM

II. Dates (important events)

Enumeration Date: 11/02/2026
Last Update Date: 11/02/2026
Certification Date: 10/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 LELAND ST
SPRING VALLEY CA
91977-4819
US

IV. Provider business mailing address

4759 DATE AVE
LA MESA CA
91942
US

V. Phone/Fax

Practice location:
  • Phone: 619-668-5702
  • Fax:
Mailing address:
  • Phone: 619-668-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number260250567
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: