Provider Demographics
NPI:1669110987
Name:MORENO, GISELLE
Entity type:Individual
Prefix:
First Name:GISELLE
Middle Name:
Last Name:MORENO
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 1:1886 TOULOUSE DR
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-2998
Mailing Address - Country:US
Mailing Address - Phone:619-600-7725
Mailing Address - Fax:
Practice Address - Street 1:1424 30TH ST STE A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-3417
Practice Address - Country:US
Practice Address - Phone:619-565-2650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-25
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14778101YP2500X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty