Healthcare Provider Details

I. General information

NPI: 1396311882
Provider Name (Legal Business Name): SOFIA MARI MOISA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17982 SKY PARK CIR STE J
IRVINE CA
92614-6482
US

IV. Provider business mailing address

1523 S VAN NESS AVE
SANTA ANA CA
92707-1613
US

V. Phone/Fax

Practice location:
  • Phone: 949-809-5790
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: