Provider Demographics
NPI:1679750947
Name:SIAHAAN, EDWARD HALOMOAN (MS, MBA, MFT INTERN)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:HALOMOAN
Last Name:SIAHAAN
Suffix:
Gender:M
Credentials:MS, MBA, MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22899 CATTAIL LN
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-6013
Mailing Address - Country:US
Mailing Address - Phone:909-553-1481
Mailing Address - Fax:951-924-7226
Practice Address - Street 1:22899 CATTAIL LN
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-6013
Practice Address - Country:US
Practice Address - Phone:909-553-1481
Practice Address - Fax:951-924-7226
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 50143101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health