Provider Demographics
NPI:1093169252
Name:MORA, CARLOS G (PCCI)
Entity Type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:G
Last Name:MORA
Suffix:
Gender:M
Credentials:PCCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 CAPP STREET
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110
Mailing Address - Country:US
Mailing Address - Phone:415-282-6209
Mailing Address - Fax:415-241-9758
Practice Address - Street 1:995 POTRERO AVENUE
Practice Address - Street 2:BUILDING 80 2ND FLOOR
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110
Practice Address - Country:US
Practice Address - Phone:628-206-3008
Practice Address - Fax:628-206-3822
Is Sole Proprietor?:No
Enumeration Date:2016-04-14
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPCCI, 1190101YM0800X
CAAPCC1190101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1190OtherPCCI