Provider Demographics
NPI:1083499610
Name:MORENO, LUIS ENRIQUE
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:ENRIQUE
Last Name:MORENO
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 1:777 N ASHLEY DR UNIT 1912
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-4374
Mailing Address - Country:US
Mailing Address - Phone:305-619-4597
Mailing Address - Fax:
Practice Address - Street 1:777 N ASHLEY DR UNIT 1912
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-4374
Practice Address - Country:US
Practice Address - Phone:305-619-4597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-287052106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician