Provider Demographics
NPI:1245757913
Name:MORENO, VIRGINA
Entity Type:Individual
Prefix:
First Name:VIRGINA
Middle Name:
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:PO BOX 174
Mailing Address - Street 2:
Mailing Address - City:TRAVER
Mailing Address - State:CA
Mailing Address - Zip Code:93673-0174
Mailing Address - Country:US
Mailing Address - Phone:559-331-1163
Mailing Address - Fax:
Practice Address - Street 1:1731 W WALNUT AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-6232
Practice Address - Country:US
Practice Address - Phone:559-732-4885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)