Healthcare Provider Details

I. General information

NPI: 1649107525
Provider Name (Legal Business Name): MIGUEL MORENO
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22122 SHERMAN WAY STE 105
CANOGA PARK CA
91303-1159
US

IV. Provider business mailing address

18300 NAPA ST APT H
NORTHRIDGE CA
91325-3604
US

V. Phone/Fax

Practice location:
  • Phone: 866-671-3645
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: