Provider Demographics
NPI:1306587837
Name:TRIPLE MOON PSYCHOTHERAPY COLLECTIVE A LICENSED CLINICAL SOCIAL WORKER
Entity type:Organization
Organization Name:TRIPLE MOON PSYCHOTHERAPY COLLECTIVE A LICENSED CLINICAL SOCIAL WORKER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:LE REVE RENDEROS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT LPCC
Authorized Official - Phone:951-870-1528
Mailing Address - Street 1:12371 LEWIS ST STE 103
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4687
Mailing Address - Country:US
Mailing Address - Phone:951-870-1528
Mailing Address - Fax:
Practice Address - Street 1:12371 LEWIS ST STE 103
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4687
Practice Address - Country:US
Practice Address - Phone:949-868-8255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-06
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100215178Medicaid