Basic Information
Provider Information | |||||||||
NPI: | 1831317841 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOHAN | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MISS | ||||||||
NameSuffix: |   | ||||||||
Credential: | MFC 31627 | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 260 MAPLE CT #225 | ||||||||
Address2: |   | ||||||||
City: | VENTURA | ||||||||
State: | CA | ||||||||
PostalCode: | 93003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8057948121 | ||||||||
FaxNumber: | 8056591740 | ||||||||
Practice Location | |||||||||
Address1: | 200 S. WELLS RD | ||||||||
Address2: | SUITE 225 | ||||||||
City: | VENTURA | ||||||||
State: | CA | ||||||||
PostalCode: | 93004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056476322 | ||||||||
FaxNumber: | 8056477164 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC 31627 |   | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | MFC31627 | 01 | CA | BOARD OF BEHAVIORAL SCIEN | OTHER |