Provider Demographics
NPI:1306634654
Name:OPAL PSYCHOLOGICAL PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:OPAL PSYCHOLOGICAL PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LADERA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:PEREZ LINN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:619-259-0107
Mailing Address - Street 1:1111 6TH AVE STE 550
Mailing Address - Street 2:#292745
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101
Mailing Address - Country:US
Mailing Address - Phone:619-259-0107
Mailing Address - Fax:
Practice Address - Street 1:4210 BROOKE CT UNIT 1405
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-5362
Practice Address - Country:US
Practice Address - Phone:619-259-0107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Single Specialty