Provider Demographics
NPI:1720361678
Name:MORENO, LIZETH (DSW)
Entity type:Individual
Prefix:
First Name:LIZETH
Middle Name:
Last Name:MORENO
Suffix:
Gender:
Credentials:DSW
Other - Prefix:
Other - First Name:LIZETH
Other - Middle Name:
Other - Last Name:RUIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20839 BROKEN BIT DR
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-3841
Mailing Address - Country:US
Mailing Address - Phone:323-864-5834
Mailing Address - Fax:
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:MS#53
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:323-361-3814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA128742101YM0800X, 1041C0700X
CA390200000X282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No282NC2000XHospitalsGeneral Acute Care HospitalChildren