Provider Demographics
NPI:1982076402
Name:MORETTI, SALLY EDEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:EDEN
Last Name:MORETTI
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 1:5920 CANYON VISTA DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-6621
Mailing Address - Country:US
Mailing Address - Phone:505-933-1807
Mailing Address - Fax:505-856-1614
Practice Address - Street 1:5920 CANYON VISTA DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-6621
Practice Address - Country:US
Practice Address - Phone:505-933-1807
Practice Address - Fax:505-856-1614
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-23
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1395103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12226203Medicaid
1053835710OtherNPI TYPE 2