Provider Demographics
NPI:1568026540
Name:MORENO, SHEILA RENE
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:RENE
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 1:1803 W MARCH LN STE C&D
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6458
Mailing Address - Country:US
Mailing Address - Phone:209-636-5353
Mailing Address - Fax:209-636-5354
Practice Address - Street 1:1803 W MARCH LN STE AC&D
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6458
Practice Address - Country:US
Practice Address - Phone:209-636-5353
Practice Address - Fax:209-636-5354
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 171M00000X, 175T00000X
CA1099001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist