Healthcare Provider Details

I. General information

NPI: 1629788724
Provider Name (Legal Business Name): ETHAN BALDWIN NOBLE MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2022
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23291 MILL CREEK DR # 200
LAGUNA HILLS CA
92653-1631
US

IV. Provider business mailing address

23291 MILL CREEK DR # 200
LAGUNA HILLS CA
92653-1631
US

V. Phone/Fax

Practice location:
  • Phone: 949-458-2715
  • Fax: 949-458-3583
Mailing address:
  • Phone: 949-458-2715
  • Fax: 949-458-3583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number151742
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: