1306634654 NPI number — OPAL PSYCHOLOGICAL PROFESSIONAL CORPORATION

Table of content: (NPI 1306634654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306634654 NPI number — OPAL PSYCHOLOGICAL PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPAL PSYCHOLOGICAL PROFESSIONAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306634654
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 6TH AVE STE 550
Provider Second Line Business Mailing Address:
#292745
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-259-0107
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4210 BROOKE CT UNIT 1405
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92122-5362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-259-0107
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/28/2025

Additional Information

Authorized Official

Authorized Official Last Name:
PEREZ LINN
Authorized Official First Name:
LADERA
Authorized Official Middle Name:
NICOLE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
619-259-0107

Provider Taxonomy Codes

  • Taxonomy code: 103TH0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com