Provider Demographics
NPI:1447387055
Name:MORENO, GUSTAVO ROBERT III
Entity Type:Individual
Prefix:MR
First Name:GUSTAVO
Middle Name:ROBERT
Last Name:MORENO
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 1:5401 BUSINESS PARK S STE 208
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93309-1661
Mailing Address - Country:US
Mailing Address - Phone:661-889-8320
Mailing Address - Fax:661-868-6666
Practice Address - Street 1:5401 BUSINESS PARK S STE 208
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-1661
Practice Address - Country:US
Practice Address - Phone:661-889-8320
Practice Address - Fax:661-748-1910
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist