Provider Demographics
NPI:1538656061
Name:MORENO, JOHN SOUL
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:SOUL
Last Name:MORENO
Suffix:
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 1:2957 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94806-2338
Mailing Address - Country:US
Mailing Address - Phone:510-327-9297
Mailing Address - Fax:
Practice Address - Street 1:2828 FORD ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2114
Practice Address - Country:US
Practice Address - Phone:510-504-2285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA128057101YM0800X, 390200000X
101YM0800X, 390200000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program