Provider Demographics
NPI:1275343857
Name:NEUROEDGE PSYCHOLOGICAL SERVICES, INC.
Entity type:Organization
Organization Name:NEUROEDGE PSYCHOLOGICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BEATRIX
Authorized Official - Middle Name:SIBYLLE
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:310-995-7427
Mailing Address - Street 1:964 EL SEGUNDO DR
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-2201
Mailing Address - Country:US
Mailing Address - Phone:310-995-7427
Mailing Address - Fax:
Practice Address - Street 1:964 EL SEGUNDO DR
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91362-2201
Practice Address - Country:US
Practice Address - Phone:310-995-7427
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1639358385OtherANTHEM BLUE CROSS
CA1639358385Medicaid
CA12409169OtherANTHEM BLUE CROSS
CAPG0112723001OtherBLUE SHIELD OF CALIFORNIA