Provider Demographics
NPI:1821587528
Name:MORENO, GEORGE (CADC-II, DDCS)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:CADC-II, DDCS
Other - Prefix:MR
Other - First Name:GEORGE
Other - Middle Name:
Other - Last Name:MORENO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CADC-II, DDCS
Mailing Address - Street 1:40356 NIDO CT
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93551-5225
Mailing Address - Country:US
Mailing Address - Phone:818-442-8050
Mailing Address - Fax:
Practice Address - Street 1:40356 NIDO CT
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-5225
Practice Address - Country:US
Practice Address - Phone:818-442-8050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA051120118101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA051120118OtherCCAPP