Provider Demographics
NPI:1659034163
Name:MORENO, MARWICK
Entity Type:Individual
Prefix:
First Name:MARWICK
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 1:5305 W 22ND CT
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33016-2045
Mailing Address - Country:US
Mailing Address - Phone:786-760-4691
Mailing Address - Fax:
Practice Address - Street 1:5305 W 22ND CT
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33016-2045
Practice Address - Country:US
Practice Address - Phone:786-760-4691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-138523106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty