Provider Demographics
NPI:1174011407
Name:MORENO, SHANTELL DIVINITY
Entity Type:Individual
Prefix:
First Name:SHANTELL
Middle Name:DIVINITY
Last Name:MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 MEDICAL ARTS AVE NE BLDG 3
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 MEDICAL ARTS AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102
Practice Address - Country:US
Practice Address - Phone:505-933-4639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2021-08-27
Deactivation Date:2021-07-22
Deactivation Code:
Reactivation Date:2021-08-25
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NMCTL0218771101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician