Provider Demographics
NPI:1639676802
Name:MORENO, LESLEY
Entity Type:Individual
Prefix:
First Name:LESLEY
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 1:2535 SW 32ND ST
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33914-4902
Mailing Address - Country:US
Mailing Address - Phone:239-233-6630
Mailing Address - Fax:
Practice Address - Street 1:2675 HORSESHOE DR S STE 404
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34104-6155
Practice Address - Country:US
Practice Address - Phone:800-217-9289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent