Healthcare Provider Details

I. General information

NPI: 1720361678
Provider Name (Legal Business Name): LIZETH MORENO DSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LIZETH RUIZ

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD MS#53
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

20839 BROKEN BIT DR
COVINA CA
91724-3841
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-3814
  • Fax:
Mailing address:
  • Phone: 323-864-5834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number390200000X
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number128742
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number128742
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: