Provider Demographics
NPI:1215521869
Name:MULDOON, KRISTA
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:MULDOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 WHITTIER AVE APT A306
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-6330
Mailing Address - Country:US
Mailing Address - Phone:951-398-9130
Mailing Address - Fax:
Practice Address - Street 1:1207 E FRUIT ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4206
Practice Address - Country:US
Practice Address - Phone:951-398-9130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-24
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1498330223101YA0400X
106H00000X, 106S00000X
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician