Provider Demographics
NPI:1205649456
Name:MORENO, THEODORE ALFRED (CCHT)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:ALFRED
Last Name:MORENO
Suffix:
Gender:M
Credentials:CCHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2634
Mailing Address - Country:US
Mailing Address - Phone:626-826-0612
Mailing Address - Fax:
Practice Address - Street 1:1910 HUNTINGTON DR UNIT 9
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-4887
Practice Address - Country:US
Practice Address - Phone:626-826-0612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-30
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health