Provider Demographics
NPI:1467003442
Name:MORENO, DAVID ALEJANDRO
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ALEJANDRO
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 1:1127 SOUTHRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NEW ULM
Mailing Address - State:MN
Mailing Address - Zip Code:56073-3655
Mailing Address - Country:US
Mailing Address - Phone:517-604-8252
Mailing Address - Fax:
Practice Address - Street 1:220 E MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-3574
Practice Address - Country:US
Practice Address - Phone:517-604-8252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-22
Last Update Date:2019-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst