Provider Demographics
NPI:1326430596
Name:MORENO, DESIREE ANNE (IMF70924)
Entity Type:Individual
Prefix:MISS
First Name:DESIREE
Middle Name:ANNE
Last Name:MORENO
Suffix:
Gender:F
Credentials:IMF70924
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13965 ARTHUR AVE.
Mailing Address - Street 2:UNIT G
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723
Mailing Address - Country:US
Mailing Address - Phone:562-375-8109
Mailing Address - Fax:
Practice Address - Street 1:13965 ARTHUR AVE.
Practice Address - Street 2:UNIT G
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723
Practice Address - Country:US
Practice Address - Phone:562-375-8109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-25
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF70924106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist