Provider Demographics
NPI:1710595590
Name:MOYANO, CARLOS A
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
Last Name:MOYANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4651 SW 100TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-5757
Mailing Address - Country:US
Mailing Address - Phone:305-548-9180
Mailing Address - Fax:
Practice Address - Street 1:4651 SW 100TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-5757
Practice Address - Country:US
Practice Address - Phone:305-548-9180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-124288106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician