Provider Demographics
NPI:1982405866
Name:MALLACH, MOIRA REGINA
Entity type:Individual
Prefix:
First Name:MOIRA
Middle Name:REGINA
Last Name:MALLACH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 BROADWAY APT 713
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-3064
Mailing Address - Country:US
Mailing Address - Phone:215-498-0783
Mailing Address - Fax:
Practice Address - Street 1:420 S BEVERLY DR
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-4426
Practice Address - Country:US
Practice Address - Phone:310-775-1866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-24
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA153235106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist