Provider Demographics
NPI:1639429723
Name:MORENO, BASILISO (MSW)
Entity Type:Individual
Prefix:
First Name:BASILISO
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 CAMBRIDGE TER APT B
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-7202
Mailing Address - Country:US
Mailing Address - Phone:201-467-9524
Mailing Address - Fax:
Practice Address - Street 1:9131 QUEENS BLVD STE 618
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5543
Practice Address - Country:US
Practice Address - Phone:718-275-0983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-15
Last Update Date:2012-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker