Provider Demographics
NPI:1679112965
Name:MORENO, KRISTA (MA)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 111469
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32911
Mailing Address - Country:US
Mailing Address - Phone:954-651-8827
Mailing Address - Fax:
Practice Address - Street 1:950 MALABAR RD SW # 111469
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-6834
Practice Address - Country:US
Practice Address - Phone:954-651-8827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-03
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMT3238106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty