Provider Demographics
NPI:1578860938
Name:MORENO, JOSEPH KELLY (PHD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:KELLY
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 1:6642 BELLEVUE ORCHARD LN
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-8067
Mailing Address - Country:US
Mailing Address - Phone:805-756-2805
Mailing Address - Fax:805-756-1134
Practice Address - Street 1:6642 BELLEVUE ORCHARD LN
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-8067
Practice Address - Country:US
Practice Address - Phone:805-756-2805
Practice Address - Fax:805-756-1134
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 13000103TF0200X
UT4940521-2501103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic