Healthcare Provider Details

I. General information

NPI: 1023837614
Provider Name (Legal Business Name): OLGA REBECCA MORENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 SANTA CLARA AVE STE 205
OAKLAND CA
94610-1323
US

IV. Provider business mailing address

166 SANTA CLARA AVE STE 205
OAKLAND CA
94610-1323
US

V. Phone/Fax

Practice location:
  • Phone: 510-601-1929
  • Fax: 510-601-1929
Mailing address:
  • Phone: 510-601-1929
  • Fax: 510-601-1947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMF163315
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: