MEDICARE: LORETTA MEAD PSYCHOLOGY 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	103TC0700X	Clinical Psychologist	24298	CA

General Provider Information

NPI Number	:	1932505088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LORETTA MEAD PSYCHOLOGY INC

Provider Business Mailing Address
First Line	:	25930 YANEZ TRAIL RD
Second Line	:
City	:	MORENO VALLEY
State	:	CA
Zip	:	92551-2101
Country	:	US
Telephone Number	:	909-242-5409
Fax Number	:

Provider Business Practice Location Address
First Line	:	5005 LA MART DR
Second Line	:	STE 100-B10
City	:	RIVERSIDE
State	:	CA
Zip	:	92507-5952
Country	:	US
Telephone Number	:	909-242-5409
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	DR. LORETTA MEAD
Credential	:	PSYD
Telephone Number	:	909-242-5409

Provider Enumeration Date	:	11/17/2014
Last Update Date	:	11/17/2014

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