Healthcare Provider Details

I. General information

NPI: 1881994838
Provider Name (Legal Business Name): ROBERT MALMBERG MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2010
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 BRISTOL ST SUITE 130
COSTA MESA CA
92626-8605
US

IV. Provider business mailing address

1202 BRISTOL ST SUITE 130
COSTA MESA CA
92626-8605
US

V. Phone/Fax

Practice location:
  • Phone: 714-437-9663
  • Fax: 714-437-9631
Mailing address:
  • Phone: 714-437-9663
  • Fax: 714-437-9631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number49169
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: