Provider Demographics
NPI:1346794047
Name:MORENO, MARIA ELIZABETH
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:ELIZABETH
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 1:4028 E DAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-6040
Mailing Address - Country:US
Mailing Address - Phone:559-283-7369
Mailing Address - Fax:
Practice Address - Street 1:4411 N CEDAR AVE STE 108
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-2538
Practice Address - Country:US
Practice Address - Phone:559-248-1548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA770534019101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100039ANMedicaid