Provider Demographics
NPI:1063782977
Name:MORAN, RAQUEL MAGDALENA (MA)
Entity type:Individual
Prefix:MISS
First Name:RAQUEL
Middle Name:MAGDALENA
Last Name:MORAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 SOUTH SUNWEST LANE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415
Mailing Address - Country:US
Mailing Address - Phone:909-252-4010
Mailing Address - Fax:
Practice Address - Street 1:1950 SOUTH SUNWEST LANE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415
Practice Address - Country:US
Practice Address - Phone:909-252-4010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-09
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program