Provider Demographics
NPI:1619678117
Name:MORENO, MICHAELA AMARIS
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:AMARIS
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 1:144 SWEET CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-8135
Mailing Address - Country:US
Mailing Address - Phone:650-444-4654
Mailing Address - Fax:
Practice Address - Street 1:144 SWEET CHERRY LN
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-8135
Practice Address - Country:US
Practice Address - Phone:650-444-4654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRBT-23252517103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst