Provider Demographics
NPI:1316728579
Name:MINDSPACE NP
Entity type:Organization
Organization Name:MINDSPACE NP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TANG
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAOQING
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:805-955-0532
Mailing Address - Street 1:7246 RHEA AVE
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-2717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2925 SYCAMORE DR STE 105
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1208
Practice Address - Country:US
Practice Address - Phone:805-955-0532
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty