Provider Demographics
NPI:1487848339
Name:MORENO, RENE (PHD)
Entity type:Individual
Prefix:MR
First Name:RENE
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1068
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-0106
Mailing Address - Country:US
Mailing Address - Phone:510-402-3387
Mailing Address - Fax:510-355-8315
Practice Address - Street 1:26081 MOCINE AVE
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94544-2923
Practice Address - Country:US
Practice Address - Phone:510-881-5921
Practice Address - Fax:510-881-5925
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27552103TC0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NPIOtherNPI