MEDICARE: CONSCIOUS CULTURE PSYCHOLOGY CLINIC INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TH0100X	Health Service Psychologist	29218	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033690235
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONSCIOUS CULTURE PSYCHOLOGY CLINIC INC.

Provider Business Mailing Address
First Line	:	5800 S EASTERN AVE STE 500
Second Line	:
City	:	COMMERCE
State	:	CA
Zip	:	90040-4033
Country	:	US
Telephone Number	:	626-658-4297
Fax Number	:

Provider Business Practice Location Address
First Line	:	5800 S EASTERN AVE
Second Line	:
City	:	COMMERCE
State	:	CA
Zip	:	90040-4016
Country	:	US
Telephone Number	:	626-430-4521
Fax Number	:	626-498-1483

Authorized Official
Title or Position	:	CEO
Name	:	DR. ANITA LOUISE MIHECOBY
Credential	:	PHD
Telephone Number	:	626-658-4297

Provider Enumeration Date	:	08/24/2018
Last Update Date	:	02/02/2023

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