Provider Demographics
NPI:1720642192
Name:LORRAINE IBOLD, LCSW COUNSELING
Entity type:Organization
Organization Name:LORRAINE IBOLD, LCSW COUNSELING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:IBOLD
Authorized Official - Last Name:LCSW
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:714-541-4921
Mailing Address - Street 1:505 N TUSTIN AVE STE 134
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3712
Mailing Address - Country:US
Mailing Address - Phone:714-541-4921
Mailing Address - Fax:714-541-4925
Practice Address - Street 1:505 N TUSTIN AVE STE 134
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3712
Practice Address - Country:US
Practice Address - Phone:714-541-4921
Practice Address - Fax:714-541-4925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-30
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1427079573OtherAETNA