Healthcare Provider Details

I. General information

NPI: 1538647680
Provider Name (Legal Business Name): MICHELLE MORENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 02/09/2026
Certification Date: 02/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6931 VAN NUYS BLVD STE 200
VAN NUYS CA
91405-3996
US

IV. Provider business mailing address

8616 LA TIJERA BLVD STE 200
LOS ANGELES CA
90045-3945
US

V. Phone/Fax

Practice location:
  • Phone: 818-989-9214
  • Fax:
Mailing address:
  • Phone: 310-337-1550
  • Fax: 800-549-4717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number136079
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberACSW90288
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW90288
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: