Basic Information
| Provider Information | |||||||||
| NPI: | 1639686652 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FROST | ||||||||
| FirstName: | MORIA | ||||||||
| MiddleName: | CAMERON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 126 MCGIVERN WAY | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950609300 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 749 37TH AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950625124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443227483 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2017 | ||||||||
| LastUpdateDate: | 12/29/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-17-27202 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.