Healthcare Provider Details

I. General information

NPI: 1346794047
Provider Name (Legal Business Name): MARIA ELIZABETH MORENO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2016
Last Update Date: 08/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 N CEDAR AVE STE 108
FRESNO CA
93726-2538
US

IV. Provider business mailing address

4028 E DAYTON AVE
FRESNO CA
93726-6040
US

V. Phone/Fax

Practice location:
  • Phone: 559-248-1548
  • Fax:
Mailing address:
  • Phone: 559-283-7369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number770534019
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: