Healthcare Provider Details

I. General information

NPI: 1245124841
Provider Name (Legal Business Name): LIBBIE MORGAN DE HETRE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2025
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14068 GRAHAM ST STE 202
MORENO VALLEY CA
92553-8830
US

IV. Provider business mailing address

189 E COUNTY LINE RD
CALIMESA CA
92320-1343
US

V. Phone/Fax

Practice location:
  • Phone: 951-649-9385
  • Fax:
Mailing address:
  • Phone: 760-261-0895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number150485
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: