Healthcare Provider Details

I. General information

NPI: 1275131401
Provider Name (Legal Business Name): LUMITOT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

198 CAPRICORN
IRVINE CA
92618-1186
US

IV. Provider business mailing address

198 CAPRICORN
IRVINE CA
92618-1186
US

V. Phone/Fax

Practice location:
  • Phone: 949-439-0195
  • Fax:
Mailing address:
  • Phone: 949-439-0195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. KAREN LISSETTE MOLANO
Title or Position: CEO
Credential: PSY.D.
Phone: 949-439-0195