Healthcare Provider Details

I. General information

NPI: 1124638051
Provider Name (Legal Business Name): ANNABELLE MARIE MORENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNABELLE MARIE BLAKEY

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 GREAT AMERICA PKWY STE 320
SANTA CLARA CA
95054-1140
US

IV. Provider business mailing address

3880 WAYNE CT
RIVERSIDE CA
92504-3129
US

V. Phone/Fax

Practice location:
  • Phone: 323-205-6101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number134990
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: