Provider Demographics
NPI:1598436222
Name:RADE MORENO, ALEX DAVID I (RBT)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:DAVID
Last Name:RADE MORENO
Suffix:I
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2167 BROOM CT
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-4601
Mailing Address - Country:US
Mailing Address - Phone:502-434-1082
Mailing Address - Fax:
Practice Address - Street 1:8359 BEACON BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3048
Practice Address - Country:US
Practice Address - Phone:239-529-0957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician