Healthcare Provider Details

I. General information

NPI: 1114464757
Provider Name (Legal Business Name): KRYSTAL MORENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2017
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E REDLANDS BLVD STE 215
REDLANDS CA
92373-4724
US

IV. Provider business mailing address

101 E REDLANDS BLVD STE 215
REDLANDS CA
92373-4724
US

V. Phone/Fax

Practice location:
  • Phone: 909-793-1078
  • Fax: 909-335-7330
Mailing address:
  • Phone: 909-793-1078
  • Fax: 909-335-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number151298
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: