Healthcare Provider Details

I. General information

NPI: 1134614522
Provider Name (Legal Business Name): RAYMOND ANTHONY MORENO BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2018
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date: 03/06/2023
Reactivation Date: 03/24/2023

III. Provider practice location address

3600 LIME ST STE 612
RIVERSIDE CA
92501-0919
US

IV. Provider business mailing address

482 HIGHLAND CT
UPLAND CA
91786-6748
US

V. Phone/Fax

Practice location:
  • Phone: 951-813-4034
  • Fax:
Mailing address:
  • Phone: 909-367-3133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number567374
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: