Provider Demographics
NPI:1326889114
Name:MORAN, ITZEL ANAHI
Entity type:Individual
Prefix:
First Name:ITZEL
Middle Name:ANAHI
Last Name:MORAN
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 1:2608 SANDSTONE ST
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-2518
Mailing Address - Country:US
Mailing Address - Phone:951-992-3396
Mailing Address - Fax:
Practice Address - Street 1:11838 BERNARDO PLAZA CT STE 110
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2414
Practice Address - Country:US
Practice Address - Phone:858-673-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-24-350254106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician