Healthcare Provider Details

I. General information

NPI: 1851212799
Provider Name (Legal Business Name): MINDFUL MOON WELLNESS, LICENSED CLINICAL SOCIAL WORKER, A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

637 MULVIHILL AVENUE
REDLANDS CA
92374-2435
US

IV. Provider business mailing address

8605 SANTA MONICA BLVD PMB 240649
WEST HOLLYWOOD CA
90069-4109
US

V. Phone/Fax

Practice location:
  • Phone: 909-545-5368
  • Fax:
Mailing address:
  • Phone: 909-545-5368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ANGELIQUE RENATE VARGAS
Title or Position: CEO/DIRECTOR
Credential:
Phone: 909-545-5368