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General NPI Number Information
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NPI Number | 1710241310
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Entity Type | Individual
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Provider Name | MICHELLE MORENO LCSW
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Gender | Female
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Dates
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Enumeration Date | 06/28/2012
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Last Update Date | 01/23/2018
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Provider Practice Location Address
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Address Line | 615 13TH ST SUITE B
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City | MODESTO
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State | CA
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Zip | 95354-2456
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Country | US
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Telephone | 209-222-3396
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Fax | 209-289-0061
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Provider Business Mailing Address
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Address Line | 615 13TH ST SUITE B
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City | MODESTO
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State | CA
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Zip | 95354-2456
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Country | US
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Telephone | 209-222-3396
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Fax | 209-289-0061
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 28058
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License Number State | CA
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