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General NPI Number Information
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NPI Number | 1538604699
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Entity Type | Organization
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Legal Business Name | THE NEW MIND WHOLE PERSON PSYCHOLOGICAL CARE INC
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Dates
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Enumeration Date | 12/28/2016
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Last Update Date | 03/01/2018
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Provider Practice Location Address
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Address Line | 114 N INDIAN HILL BLVD SUITE B
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City | CLAREMONT
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State | CA
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Zip | 91711-4675
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Country | US
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Telephone | 909-603-9300
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Fax | 909-603-9301
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Provider Business Mailing Address
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Address Line | 114 N INDIAN HILL BLVD SUITE B
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City | CLAREMONT
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State | CA
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Zip | 91711-4675
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Country | US
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Telephone | 909-603-9300
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Fax | 909-603-9301
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | DR. DENNIS W. WALLSTROM
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Credential | PH.D.
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Telephone | 909-603-9300
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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 | PSY13058
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License Number State | CA
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