=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972993509
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITY PSYCHOLOGY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2015
-----------------------------------------------------
Last Update Date | 01/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 909 15TH ST STE 8
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95354-1130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-529-7807
-----------------------------------------------------
Fax | 209-529-7919
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 721
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95353-0721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-529-7807
-----------------------------------------------------
Fax | 209-529-7919
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CYNTHIA VINCENT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 209-529-7807
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY17076
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------