Healthcare Provider Details

I. General information

NPI: 1982076402
Provider Name (Legal Business Name): SALLY EDEN MORETTI PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2015
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5920 CANYON VISTA DR NE
ALBUQUERQUE NM
87111-6621
US

IV. Provider business mailing address

5920 CANYON VISTA DR NE
ALBUQUERQUE NM
87111-6621
US

V. Phone/Fax

Practice location:
  • Phone: 505-933-1807
  • Fax: 505-856-1614
Mailing address:
  • Phone: 505-933-1807
  • Fax: 505-856-1614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1395
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: