Basic Information
| Provider Information | |||||||||
| NPI: | 1881156115 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORENO | ||||||||
| FirstName: | ANA | ||||||||
| MiddleName: | DAISY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16443 FREESIA CT | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923361464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264821601 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3075 MYERS ST | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925035525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513584625 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2019 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 93-0670286 | 05 | CA | MEDICAID |