Provider Demographics
NPI:1407219090
Name:MORENO, EVELINA
Entity Type:Individual
Prefix:
First Name:EVELINA
Middle Name:
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 1:1509 1ST AVENUE
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361
Mailing Address - Country:US
Mailing Address - Phone:308-635-1488
Mailing Address - Fax:308-635-7880
Practice Address - Street 1:1509 1ST AVE
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-3106
Practice Address - Country:US
Practice Address - Phone:308-635-1488
Practice Address - Fax:308-635-7880
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE251B00000X
NEP-1621101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No251B00000XAgenciesCase Management