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Organization
TRIPLE MOON PSYCHOTHERAPY COLLECTIVE A LICENSED CLINICAL SOCIAL WORKER
Active
Organization
TRIPLE MOON PSYCHOTHERAPY COLLECTIVE A LICENSED CLINICAL SOCIAL WORKER
Active
Other names
Triple Moon Psychotherapy Collective A Licensed Social Worker Corp, Triple Moon Psychotherapy Collective
Organization subpart
No
Provider details
NPI number
Authorized official
AMY LE REVE RENDEROS LMFT LPCC (DIRECTOR)
(951) 870-1528
Entity
Organization
Contact information
Practice address
12371 LEWIS ST STE 103, GARDEN GROVE, CA 92840-4687
(949) 868-8255
Mailing address
12371 LEWIS ST STE 103, GARDEN GROVE, CA 92840-4687
(951) 870-1528
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100215178
—
CA
Enumeration date
04/06/2022
Last updated
10/04/2023
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