Healthcare Provider Details

I. General information

NPI: 1609367515
Provider Name (Legal Business Name): MINDFUL PRACTICE INCORPORATED A PSYCHOLOGICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 10/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28544 OLD TOWN FRONT ST STE 300
TEMECULA CA
92590-2762
US

IV. Provider business mailing address

31805 TEMECULA PKWY # 552
TEMECULA CA
92592-8203
US

V. Phone/Fax

Practice location:
  • Phone: 909-262-8325
  • Fax:
Mailing address:
  • Phone: 909-262-8832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberPSY14246
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberPSY14246
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberPSY14246
License Number StateCA

VIII. Authorized Official

Name: RENDA DIONNE MADRIGAL
Title or Position: PRESIDENT
Credential: PHD
Phone: 909-262-8325