Healthcare Provider Details

I. General information

NPI: 1790261659
Provider Name (Legal Business Name): VANESSA TARIN MORENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2018
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 1531
LA MIRADA CA
90637-1531
US

IV. Provider business mailing address

5849 CROCKER ST UNIT L
LOS ANGELES CA
90003-1311
US

V. Phone/Fax

Practice location:
  • Phone: 714-900-3951
  • Fax:
Mailing address:
  • Phone: 714-900-3951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number157660
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: