Provider Demographics
NPI:1932648409
Name:LEE-MORENO, DEBRA J (PSYD)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:J
Last Name:LEE-MORENO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 LAS POSAS
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-4006
Mailing Address - Country:US
Mailing Address - Phone:714-469-8957
Mailing Address - Fax:
Practice Address - Street 1:1108 LAS POSAS
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-4006
Practice Address - Country:US
Practice Address - Phone:714-469-8957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT52705106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist