Healthcare Provider Details

I. General information

NPI: 1245864990
Provider Name (Legal Business Name): ANGEL MORA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2020
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 E N ST
COLTON CA
92324-3432
US

IV. Provider business mailing address

431 MACKAY DR
SAN BERNARDINO CA
92408-3222
US

V. Phone/Fax

Practice location:
  • Phone: 951-454-6844
  • Fax:
Mailing address:
  • Phone: 909-433-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: