Provider Demographics
NPI:1366198319
Name:MORELAND, SOCORRO
Entity type:Individual
Prefix:MR
First Name:SOCORRO
Middle Name:
Last Name:MORELAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 N ARGONAUT ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95203-2108
Mailing Address - Country:US
Mailing Address - Phone:510-543-3249
Mailing Address - Fax:
Practice Address - Street 1:3123 INDEPENDENCE DR
Practice Address - Street 2:
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94551-7595
Practice Address - Country:US
Practice Address - Phone:925-999-4119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-28
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101YM0800XMedicaid