Healthcare Provider Details

I. General information

NPI: 1093447088
Provider Name (Legal Business Name): CARLOS ANDRES MORENO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 S LAKE ERIE DR STE B
WEST VALLEY CITY UT
84120-7351
US

IV. Provider business mailing address

2655 S LAKE ERIE DR STE B
WEST VALLEY CITY UT
84120-7351
US

V. Phone/Fax

Practice location:
  • Phone: 385-441-4900
  • Fax:
Mailing address:
  • Phone: 385-441-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number13494100-3904
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: