Provider Demographics
NPI:1578233839
Name:MORALEZ, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:MORALEZ
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 1:3720 THREE SAINTS RD
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:NM
Mailing Address - Zip Code:88021-8928
Mailing Address - Country:US
Mailing Address - Phone:415-535-3885
Mailing Address - Fax:
Practice Address - Street 1:3720 THREE SAINTS RD
Practice Address - Street 2:
Practice Address - City:ANTHONY
Practice Address - State:NM
Practice Address - Zip Code:88021-8928
Practice Address - Country:US
Practice Address - Phone:415-535-3885
Practice Address - Fax:575-882-2448
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
NM172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No251S00000XAgenciesCommunity/Behavioral Health