Provider Demographics
NPI:1528404316
Name:IDENTICORP
Entity Type:Organization
Organization Name:IDENTICORP
Other - Org Name:MOLTER COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MOLTER
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:949-742-0669
Mailing Address - Street 1:19389 LIVE OAK CANYON RD
Mailing Address - Street 2:
Mailing Address - City:TRABUCO CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:92679-3037
Mailing Address - Country:US
Mailing Address - Phone:949-742-0669
Mailing Address - Fax:949-858-5431
Practice Address - Street 1:27001 LA PAZ RD STE 401
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5502
Practice Address - Country:US
Practice Address - Phone:949-742-0669
Practice Address - Fax:949-858-5431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC46701101YM0800X
CAMFC46277101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty