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General NPI Number Information
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NPI Number | 1851212799
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Entity Type | Organization
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Legal Business Name | MINDFUL MOON WELLNESS, LICENSED CLINICAL SOCIAL WORKER, A PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 07/24/2026
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Last Update Date | 07/24/2026
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Provider Practice Location Address
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Address Line | 637 MULVIHILL AVENUE
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City | REDLANDS
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State | CA
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Zip | 92374-2435
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Country | US
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Telephone | 909-545-5368
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Fax |
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Provider Business Mailing Address
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Address Line | 8605 SANTA MONICA BLVD PMB 240649
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City | WEST HOLLYWOOD
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State | CA
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Zip | 90069-4109
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Country | US
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Telephone | 909-545-5368
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Fax |
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Authorized Official
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Title or Position | CEO/DIRECTOR
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Name | ANGELIQUE RENATE VARGAS
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Credential |
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Telephone | 909-545-5368
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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