Healthcare Provider Details

I. General information

NPI: 1962006486
Provider Name (Legal Business Name): MOXIE FAMILY THERAPY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2020
Last Update Date: 08/17/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17772 IRVINE BLVD STE 209
TUSTIN CA
92780-3234
US

IV. Provider business mailing address

17772 IRVINE BLVD STE 209
TUSTIN CA
92780-3234
US

V. Phone/Fax

Practice location:
  • Phone: 714-388-6119
  • Fax:
Mailing address:
  • Phone: 714-388-6119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MELISSA ANN MELLON
Title or Position: FOUNDER AND DIRECTOR
Credential: LMFT
Phone: 714-388-6119