Healthcare Provider Details

I. General information

NPI: 1881822575
Provider Name (Legal Business Name): GLORIA MARINA MORENO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14609 MARYTON AVE
NORWALK CA
90650-5152
US

IV. Provider business mailing address

5835 S EASTERN AVE
COMMERCE CA
90040-4029
US

V. Phone/Fax

Practice location:
  • Phone: 562-404-9790
  • Fax: 562-404-9790
Mailing address:
  • Phone: 323-725-4629
  • Fax: 323-728-9201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number22510
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS22510
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: