Provider Demographics
NPI:1649734724
Name:MOYA-MAGANA, IMELDA (APCC5854)
Entity Type:Individual
Prefix:
First Name:IMELDA
Middle Name:
Last Name:MOYA-MAGANA
Suffix:
Gender:F
Credentials:APCC5854
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1429 VIA SALERNO
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-2252
Mailing Address - Country:US
Mailing Address - Phone:661-305-4596
Mailing Address - Fax:
Practice Address - Street 1:2125 CITRACADO PKWY STE 200
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92029-4159
Practice Address - Country:US
Practice Address - Phone:760-294-9270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA5854101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YMO800XMedicaid
CA101YM0800XMedicaid