Provider Demographics
NPI:1134874258
Name:MOSES, KEAALIYAH
Entity type:Individual
Prefix:
First Name:KEAALIYAH
Middle Name:
Last Name:MOSES
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 1:2741 PARK AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-4211
Mailing Address - Country:US
Mailing Address - Phone:909-688-3904
Mailing Address - Fax:
Practice Address - Street 1:2741 PARK AVE APT 9
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4211
Practice Address - Country:US
Practice Address - Phone:909-688-3904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician