Provider Demographics
NPI:1659003382
Name:MORENO, ALEXIS WALESKA
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:WALESKA
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 1:3601 CALLE TECATE STE 201
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5056
Mailing Address - Country:US
Mailing Address - Phone:805-289-0120
Mailing Address - Fax:805-289-0130
Practice Address - Street 1:3601 CALLE TECATE STE 201
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-5056
Practice Address - Country:US
Practice Address - Phone:805-289-0120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA56CCOtherASPIRA