Basic Information
| Provider Information | |||||||||
| NPI: | 1790811073 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORONI | ||||||||
| FirstName: | BRANDAN | ||||||||
| MiddleName: | CHACE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2077 | ||||||||
| Address2: | |||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954822077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074672010 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9981 SPRING VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | POTTER VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954699713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074672010 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 697568 | CA | N | Behavioral Health & Social Service Providers | Counselor | 171M00000X | 697568 | CA | N | Other Service Providers | Case Manager/Care Coordinator | 164X00000X | 697568 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.