Provider Demographics
NPI:1063290641
Name:MORENO, MIREYA LILIANA
Entity type:Individual
Prefix:
First Name:MIREYA
Middle Name:LILIANA
Last Name:MORENO
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 1:9269 VILLAGE GLEN DR UNIT 229
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2484
Mailing Address - Country:US
Mailing Address - Phone:619-250-1441
Mailing Address - Fax:
Practice Address - Street 1:9269 VILLAGE GLEN DR UNIT 229
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2484
Practice Address - Country:US
Practice Address - Phone:619-250-1441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician