Provider Demographics
NPI:1366845232
Name:PACHECO, MOSES III
Entity Type:Individual
Prefix:
First Name:MOSES
Middle Name:
Last Name:PACHECO
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 W BRIGGSMORE AVE
Mailing Address - Street 2:SUITE I
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-3839
Mailing Address - Country:US
Mailing Address - Phone:209-526-1440
Mailing Address - Fax:209-550-4903
Practice Address - Street 1:2000 W BRIGGSMORE AVE
Practice Address - Street 2:SUITE I
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-3839
Practice Address - Country:US
Practice Address - Phone:209-526-1440
Practice Address - Fax:209-550-4903
Is Sole Proprietor?:No
Enumeration Date:2014-10-06
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA123462101YP2500X
CA127871106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional