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General NPI Number Information
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NPI Number | 1134375983
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Entity Type | Organization
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Legal Business Name | PSYCHOLOGICAL WELLNESS
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Dates
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Enumeration Date | 08/12/2008
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Last Update Date | 08/12/2008
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Provider Practice Location Address
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Address Line | 806 MANHATTAN BEACH BLVD STE. 207
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City | MANHATTAN BEACH
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State | CA
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Zip | 90266-4935
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Country | US
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Telephone | 310-376-3388
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Fax | 310-372-0198
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Provider Business Mailing Address
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Address Line | 806 MANHATTAN BEACH BLVD STE. 207
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City | MANHATTAN BEACH
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State | CA
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Zip | 90266-4935
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Country | US
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Telephone | 310-376-3388
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Fax | 310-372-0198
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. VIVIAN CREDIDIO
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Credential | PH.D.
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Telephone | 310-376-3388
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY10441
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License Number State | CA
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