Intricate Mind Institute, LLC

Primary specialty

Cognitive & Behavioral PsychologistTaxonomy code 103TB0200X

License

PSY17553 Issued in CA

Legal business name

INTRICATE MIND INSTITUTE, LLC

Practice address

3990 Old Town Ave Ste A207
San Diego, CA 92110-2967

Phone

(858) 205-9809

Fax

(858) 205-9809

NPI assigned

Nov 9, 2011

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Mary J Baker-Ericzen, PH.D.NPI 1144330382

Title

Director

Phone

(858) 205-9809

Specialties & licenses 2

Addresses

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Mary J Baker-Ericzen, PHD

  • Intellectual & Developmental Disabilities Psychologist
  • San Diego, CA
  • NPI 1144330382
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1320796800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1320796800000",
    "number": "1457638124",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3990 OLD TOWN AVE STE A207",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921102967",
            "telephone_number": "858-205-9809",
            "fax_number": "858-205-9809"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3990 OLD TOWN AVE STE A207",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921102967",
            "telephone_number": "858-205-9809",
            "fax_number": "858-205-9809"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTRICATE MIND INSTITUTE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-11-09",
        "last_updated": "2011-11-09",
        "status": "A",
        "authorized_official_last_name": "BAKER-ERICZEN",
        "authorized_official_first_name": "MARY",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "858-205-9809",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PH.D."
    },
    "taxonomies": [
        {
            "code": "103TB0200X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Cognitive & Behavioral",
            "state": "CA",
            "license": "PSY17553",
            "primary": true
        },
        {
            "code": "103TM1800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Intellectual & Developmental Disabilities",
            "state": "CA",
            "license": "PSY23448",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Cognitive & Behavioral Psychologist in San Diego, CA
• Providers in San Diego, CA by specialty
• Cognitive & Behavioral Psychologist in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 9, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.