Provider Demographics
NPI:1538992854
Name:MOUA, MAIV NTXAWM MARYANNE
Entity type:Individual
Prefix:
First Name:MAIV
Middle Name:NTXAWM MARYANNE
Last Name:MOUA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 E 2ND ST APT 3
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3749
Mailing Address - Country:US
Mailing Address - Phone:916-416-6410
Mailing Address - Fax:
Practice Address - Street 1:500 CITY PKWY W STE 400
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2941
Practice Address - Country:US
Practice Address - Phone:714-834-7769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-22
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker