Healthcare Provider Details

I. General information

NPI: 1578860938
Provider Name (Legal Business Name): JOSEPH KELLY MORENO PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2011
Last Update Date: 02/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6642 BELLEVUE ORCHARD LN
SAN LUIS OBISPO CA
93405-8067
US

IV. Provider business mailing address

6642 BELLEVUE ORCHARD LN
SAN LUIS OBISPO CA
93405-8067
US

V. Phone/Fax

Practice location:
  • Phone: 805-756-2805
  • Fax: 805-756-1134
Mailing address:
  • Phone: 805-756-2805
  • Fax: 805-756-1134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY 13000
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number4940521-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: