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General NPI Number Information
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NPI Number | 1306634654
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Entity Type | Organization
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Legal Business Name | OPAL PSYCHOLOGICAL PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 04/28/2025
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Last Update Date | 04/28/2025
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Provider Practice Location Address
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Address Line | 4210 BROOKE CT UNIT 1405
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City | SAN DIEGO
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State | CA
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Zip | 92122-5362
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Country | US
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Telephone | 619-259-0107
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Fax |
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Provider Business Mailing Address
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Address Line | 1111 6TH AVE STE 550 #292745
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City | SAN DIEGO
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State | CA
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Zip | 92101
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Country | US
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Telephone | 619-259-0107
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | LADERA NICOLE PEREZ LINN
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Credential | PSYD
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Telephone | 619-259-0107
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TH0004X
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Taxonomy Name | Health Psychologist
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License Number |
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License Number State |
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