Provider Demographics
NPI:1699468777
Name:CERVANTES-MORALES, MICHELLE JACQUELINE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JACQUELINE
Last Name:CERVANTES-MORALES
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 1:91180 64TH AVE APT 404
Mailing Address - Street 2:
Mailing Address - City:MECCA
Mailing Address - State:CA
Mailing Address - Zip Code:92254-7060
Mailing Address - Country:US
Mailing Address - Phone:760-609-9384
Mailing Address - Fax:
Practice Address - Street 1:69930 HIGHWAY 111 STE 118
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-2853
Practice Address - Country:US
Practice Address - Phone:760-670-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician