Healthcare Provider Details

I. General information

NPI: 1750751178
Provider Name (Legal Business Name): MHA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2015
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W 19TH ST STE B
COSTA MESA CA
92627-2026
US

IV. Provider business mailing address

26 WAKEFIELD
IRVINE CA
92620-3288
US

V. Phone/Fax

Practice location:
  • Phone: 949-646-9227
  • Fax:
Mailing address:
  • Phone: 949-751-8826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. CHRISTOPHER H NGUYEN
Title or Position: REHABILITATION WORKER
Credential:
Phone: 949-751-8826