Provider Demographics
NPI:1043646383
Name:MORENO, ANDY R (MFTI, RASI)
Entity Type:Individual
Prefix:MR
First Name:ANDY
Middle Name:R
Last Name:MORENO
Suffix:
Gender:M
Credentials:MFTI, RASI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7790 BIG ROCK DR.
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509
Mailing Address - Country:US
Mailing Address - Phone:951-500-4497
Mailing Address - Fax:
Practice Address - Street 1:7790 BIG ROCK DR.
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92509
Practice Address - Country:US
Practice Address - Phone:951-500-4497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARI-M1305212002101YA0400X
CAIMF 65612106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)