NPIMap

Organization Active NPI

Triple Moon Psychotherapy Collective a Licensed Clinical Social Worker

Doing business as Triple Moon Psychotherapy Collective

  • Clinical Social Worker
  • Garden Grove, CA
National Provider Identifier
1306587837
Registry record updated Oct 4, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Social WorkerTaxonomy code 1041C0700X
Legal business name
TRIPLE MOON PSYCHOTHERAPY COLLECTIVE A LICENSED CLINICAL SOCIAL WORKER
Doing business as
Triple Moon Psychotherapy Collective
Practice address
12371 Lewis St Ste 103
Garden Grove, CA 92840-4687
Phone
(949) 868-8255
NPI assigned
Apr 6, 2022
Last updated
Oct 4, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 4, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Amy Le Reve Renderos, LMFT LPCCNPI 1083067748
Title
Director
Phone
(951) 870-1528

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Social Worker 1041C0700X NU Primary

Addresses

Primary practice location

12371 Lewis St Ste 103
Garden Grove, CA 92840-4687

Mailing address

12371 Lewis St Ste 103
Garden Grove, CA 92840-4687
Phone (951) 870-1528

Other identifiers 1

IdentifierTypeStateIssuer
100215178MedicaidCA

Other names 2

  • Triple Moon Psychotherapy Collective Doing business as
  • Triple Moon Psychotherapy Collective A Licensed Social Worker Corp Other name

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://www.triplemoonpsych.com/ Direct

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1649203200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1696377600000",
    "number": "1306587837",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12371 LEWIS ST STE 103",
            "city": "GARDEN GROVE",
            "state": "CA",
            "postal_code": "928404687",
            "telephone_number": "951-870-1528"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12371 LEWIS ST STE 103",
            "city": "GARDEN GROVE",
            "state": "CA",
            "postal_code": "928404687",
            "telephone_number": "949-868-8255"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TRIPLE MOON PSYCHOTHERAPY COLLECTIVE A LICENSED CLINICAL SOCIAL WORKER",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-04-06",
        "last_updated": "2023-10-04",
        "certification_date": "2023-10-04",
        "status": "A",
        "authorized_official_last_name": "LE REVE RENDEROS",
        "authorized_official_first_name": "AMY",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "951-870-1528",
        "authorized_official_credential": "LMFT LPCC"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100215178",
            "state": "CA"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://www.triplemoonpsych.com/",
            "affiliation": "N",
            "endpointDescription": "Website",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "12371 Lewis St Ste 103",
            "city": "Garden Grove",
            "state": "CA",
            "country_code": "US",
            "postal_code": "928404687",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Triple Moon Psychotherapy Collective",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Triple Moon Psychotherapy Collective A Licensed Social Worker Corp",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Garden Grove, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 4, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.