Healthcare Provider Details

I. General information

NPI: 1285456905
Provider Name (Legal Business Name): THERAQ, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2024
Last Update Date: 10/25/2024
Certification Date: 10/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17752 SKY PARK CIRCLE SUITE 245
IRVINE CA
92614
US

IV. Provider business mailing address

20409 YORBA LINDA BLVD STE 237
YORBA LINDA CA
92886-3042
US

V. Phone/Fax

Practice location:
  • Phone: 714-922-0720
  • Fax:
Mailing address:
  • Phone: 714-922-0720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. KATHERINE MOORE
Title or Position: OFFICER OF THE BOARD OF DIRECTORS
Credential: PSYD
Phone: 714-922-0720