1851055123 NPI number — EDMOND CHILD AND FAMILY COUNSELING, CLARK D EDMOND, LICENSED CLINICAL

Table of content: MRS. JOHANNA ANJA MOLENDIJK PT (NPI 1336230283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851055123 NPI number — EDMOND CHILD AND FAMILY COUNSELING, CLARK D EDMOND, LICENSED CLINICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDMOND CHILD AND FAMILY COUNSELING, CLARK D EDMOND, LICENSED CLINICAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1851055123
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40960 CALIFORNIA OAKS RD # 220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MURRIETA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92562-5747
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-676-5154
Provider Business Mailing Address Fax Number:
951-516-1015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
41690 IVY ST STE B6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MURRIETA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92562-9436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-676-5154
Provider Business Practice Location Address Fax Number:
951-526-1015
Provider Enumeration Date:
10/23/2021

Additional Information

Authorized Official

Authorized Official Last Name:
EDMOND
Authorized Official First Name:
CLARK
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
951-775-0032

Provider Taxonomy Codes

  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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