Provider Demographics
NPI:1811220080
Name:MORENO - FIMBRES, NADINE CHRISTINE
Entity Type:Individual
Prefix:
First Name:NADINE
Middle Name:CHRISTINE
Last Name:MORENO - FIMBRES
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 1:1005 W TERESA ST
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-1714
Mailing Address - Country:US
Mailing Address - Phone:626-222-2573
Mailing Address - Fax:
Practice Address - Street 1:8939 S SEPULVEDA BLVD STE 406
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3646
Practice Address - Country:US
Practice Address - Phone:626-222-2573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-04
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76378104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker