Healthcare Provider Details

I. General information

NPI: 1417061615
Provider Name (Legal Business Name): LYNN MOLLER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 SPRING ST SUITE 204
LA MESA CA
91941-5263
US

IV. Provider business mailing address

4700 SPRING ST SUITE 204
LA MESA CA
91941-5263
US

V. Phone/Fax

Practice location:
  • Phone: 619-466-1994
  • Fax: 619-589-6840
Mailing address:
  • Phone: 619-466-1994
  • Fax: 619-589-6840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS12399
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: