Provider Demographics
NPI:1780189258
Name:MORELAND, LLEWELLYN
Entity Type:Individual
Prefix:
First Name:LLEWELLYN
Middle Name:
Last Name:MORELAND
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 1:2026 N RIVERSIDE AVE # C105
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92377-4685
Mailing Address - Country:US
Mailing Address - Phone:323-873-4705
Mailing Address - Fax:
Practice Address - Street 1:2026 N RIVERSIDE AVE # C105
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92377-4685
Practice Address - Country:US
Practice Address - Phone:323-873-4705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician