Provider Demographics
NPI:1154776763
Name:MORENO, CHRISTINA ANN (SUDCCII 9479)
Entity type:Individual
Prefix:MRS
First Name:CHRISTINA
Middle Name:ANN
Last Name:MORENO
Suffix:
Gender:F
Credentials:SUDCCII 9479
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 COLOMA WAY STE C
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4480
Mailing Address - Country:US
Mailing Address - Phone:916-774-6647
Mailing Address - Fax:916-774-6456
Practice Address - Street 1:1133 COLOMA WAY STE C
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4480
Practice Address - Country:US
Practice Address - Phone:916-774-6647
Practice Address - Fax:916-774-6456
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASUDCCII101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)