| Myndloft Licensed Clinical Social Worker Professional Corporation | |
|
240 W Chapman Ave Ste 200 Orange CA 92866-1316 | |
| (855) 750-5010 | |
| (619) 354-1803 |
| Full Name | Myndloft Licensed Clinical Social Worker Professional Corporation |
|---|---|
| Speciality | Social Worker |
| Location | 240 W Chapman Ave Ste 200, Orange, California |
| Authorized Official Name and Position | Dale Elery Werner (ADMINISTRATOR) |
| Authorized Official Contact | 9495699226 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Myndloft Licensed Clinical Social Worker Professional Corporation Po Box 3340 Tustin CA 92781-3340 Ph: (855) 750-5010 | Myndloft Licensed Clinical Social Worker Professional Corporation 240 W Chapman Ave Ste 200 Orange CA 92866-1316 Ph: (855) 750-5010 |
| NPI Number | 1093415481 |
|---|---|
| Provider Enumeration Date | 03/06/2023 |
| Last Update Date | 05/03/2023 |
| Certification Date | 05/03/2023 |
| Medicare PECOS PAC ID | 9335588466 |
|---|---|
| Medicare Enrollment ID | O20240422002102 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1093415481 | NPI | - | NPPES |
| Provider Name | Kelly Rauch |
|---|---|
| Provider Type | Practitioner - Marriage And Family Therapist |
| Provider Identifiers | NPI Number: 1336607688 PECOS PAC ID: 4385081033 Enrollment ID: I20240416000957 |
| Provider Name | Alexander Petro |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1891455390 PECOS PAC ID: 8820467806 Enrollment ID: I20240517002591 |
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