Provider Demographics
NPI:1245864990
Name:MORA, ANGEL
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:
Last Name:MORA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 MACKAY DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3222
Mailing Address - Country:US
Mailing Address - Phone:909-433-9300
Mailing Address - Fax:
Practice Address - Street 1:335 E N ST
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3432
Practice Address - Country:US
Practice Address - Phone:951-454-6844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-02
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X, 1041S0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool