Provider Demographics
NPI:1568884666
Name:MORENO, ALEC
Entity Type:Individual
Prefix:
First Name:ALEC
Middle Name:
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 1:908 S LEE ST STE A
Mailing Address - Street 2:
Mailing Address - City:FORT GIBSON
Mailing Address - State:OK
Mailing Address - Zip Code:74434-8735
Mailing Address - Country:US
Mailing Address - Phone:918-203-3789
Mailing Address - Fax:918-203-3116
Practice Address - Street 1:908 S LEE ST STE A
Practice Address - Street 2:
Practice Address - City:FORT GIBSON
Practice Address - State:OK
Practice Address - Zip Code:74434-8735
Practice Address - Country:US
Practice Address - Phone:918-203-3789
Practice Address - Fax:918-203-3116
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-09
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200540800BMedicaid