Provider Demographics
NPI:1518463843
Name:MORENO, MILDREY
Entity Type:Individual
Prefix:
First Name:MILDREY
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 1:5625 W 20TH AVE APT 402
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7525
Mailing Address - Country:US
Mailing Address - Phone:786-488-2831
Mailing Address - Fax:305-742-2190
Practice Address - Street 1:5625 W 20TH AVE APT 402
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7525
Practice Address - Country:US
Practice Address - Phone:786-488-2831
Practice Address - Fax:305-742-2190
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician