=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639891682
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BUENA VIBRA PSYCHOLOGICAL SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2022
-----------------------------------------------------
Last Update Date | 10/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18000 STUDEBAKER RD STE 700
-----------------------------------------------------
City | CERRITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90703-2684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-864-0516
-----------------------------------------------------
Fax | 323-364-5676
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18000 STUDEBAKER RD STE 700
-----------------------------------------------------
City | CERRITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90703-2684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-864-0516
-----------------------------------------------------
Fax | 323-364-5676
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | MILDRED ORTIZ
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 310-864-0516
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------