Provider Demographics
NPI:1184841223
Name:MOFFATT, LADRINA A (MFT)
Entity Type:Individual
Prefix:MS
First Name:LADRINA
Middle Name:A
Last Name:MOFFATT
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MS
Other - First Name:LADRINA
Other - Middle Name:A
Other - Last Name:HEARN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:780 E GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-1003
Mailing Address - Country:US
Mailing Address - Phone:909-932-4956
Mailing Address - Fax:
Practice Address - Street 1:780 E GILBERT ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-3905
Practice Address - Country:US
Practice Address - Phone:909-693-2495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC42460106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist