Provider Demographics
NPI:1174504138
Name:MOTTOLA, CAROLYN ANNE (PHD)
Entity Type:Individual
Prefix:MISS
First Name:CAROLYN
Middle Name:ANNE
Last Name:MOTTOLA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8342
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92615-8342
Mailing Address - Country:US
Mailing Address - Phone:714-237-4440
Mailing Address - Fax:714-839-7460
Practice Address - Street 1:1020 S ANAHEIM BLVD
Practice Address - Street 2:SUITE 215
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92708
Practice Address - Country:US
Practice Address - Phone:714-237-4440
Practice Address - Fax:714-839-7460
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10163103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL101631OtherBLUE SHIELD
CA4124629OtherAETNA
CA077554OtherMANAGED HEALTH NETWORK
CAR86254Medicare UPIN
CACP10163AMedicare ID - Type Unspecified