Healthcare Provider Details

I. General information

NPI: 1932848991
Provider Name (Legal Business Name): MBLDN PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2022
Last Update Date: 05/28/2022
Certification Date: 05/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S ANAHEIM HILLS RD STE 246
ANAHEIM CA
92807-4760
US

IV. Provider business mailing address

500 S ANAHEIM HILLS RD STE 246
ANAHEIM CA
92807-4760
US

V. Phone/Fax

Practice location:
  • Phone: 949-414-9495
  • Fax:
Mailing address:
  • Phone: 949-414-9495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICOLE MOTAKEF
Title or Position: PRESIDENT
Credential: DO
Phone: 951-201-1453