Provider Demographics
NPI:1790085363
Name:MORENO-DERKS, MATTHYS ALEJANDRO
Entity Type:Individual
Prefix:
First Name:MATTHYS
Middle Name:ALEJANDRO
Last Name:MORENO-DERKS
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 1:516 31ST ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3204
Mailing Address - Country:US
Mailing Address - Phone:760-554-3507
Mailing Address - Fax:
Practice Address - Street 1:516 31ST ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3204
Practice Address - Country:US
Practice Address - Phone:760-554-3507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-28
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program