Provider Demographics
NPI:1336504687
Name:MORENO, AMANDA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:
Last Name: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 1:253 10TH AVE
Mailing Address - Street 2:UNIT 624
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-7453
Mailing Address - Country:US
Mailing Address - Phone:619-417-4779
Mailing Address - Fax:
Practice Address - Street 1:CALIFORNIA MENS COLONY
Practice Address - Street 2:HIGHWAY 1
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93409-0001
Practice Address - Country:US
Practice Address - Phone:805-547-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103TF0200X
CA31063103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic