Provider Demographics
NPI:1134614522
Name:MORENO, RAYMOND ANTHONY (BCBA)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:ANTHONY
Last Name:MORENO
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:482 HIGHLAND CT
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-6748
Mailing Address - Country:US
Mailing Address - Phone:909-367-3133
Mailing Address - Fax:
Practice Address - Street 1:3600 LIME ST STE 612
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-0919
Practice Address - Country:US
Practice Address - Phone:951-813-4034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-27
Last Update Date:2023-03-24
Deactivation Date:2023-03-06
Deactivation Code:
Reactivation Date:2023-03-24
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA567374103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician