Healthcare Provider Details

I. General information

NPI: 1043646383
Provider Name (Legal Business Name): ANDY R MORENO MFTI, RASI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2013
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7790 BIG ROCK DR.
RIVERSIDE CA
92509
US

IV. Provider business mailing address

7790 BIG ROCK DR.
RIVERSIDE CA
92509
US

V. Phone/Fax

Practice location:
  • Phone: 951-500-4497
  • Fax:
Mailing address:
  • Phone: 951-500-4497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRI-M1305212002
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF 65612
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: