Healthcare Provider Details

I. General information

NPI: 1427630342
Provider Name (Legal Business Name): IVAN PAUL MORALES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2021
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39155 LIBERTY ST STE E500
FREMONT CA
94538-1516
US

IV. Provider business mailing address

4210 TECHNOLOGY DR
FREMONT CA
94538-6337
US

V. Phone/Fax

Practice location:
  • Phone: 510-574-2114
  • Fax:
Mailing address:
  • Phone: 510-657-2350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number135228
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: