Provider Demographics
NPI:1457916504
Name:MORENO, MARILYN ADRIANA
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:ADRIANA
Last Name:MORENO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 695
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:94565-0069
Mailing Address - Country:US
Mailing Address - Phone:925-864-9735
Mailing Address - Fax:
Practice Address - Street 1:2005 MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:OAKLEY
Practice Address - State:CA
Practice Address - Zip Code:94561-3301
Practice Address - Country:US
Practice Address - Phone:925-776-8223
Practice Address - Fax:925-625-5101
Is Sole Proprietor?:No
Enumeration Date:2019-05-03
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100213104100000X, 390200000X
390200000X
CA1293561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program