Provider Demographics
NPI:1750636791
Name:MORENO, EDREY S (LMT,MMP)
Entity Type:Individual
Prefix:MRS
First Name:EDREY
Middle Name:S
Last Name:MORENO
Suffix:
Gender:F
Credentials:LMT,MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:698 SW PORT ST LUCIE BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1565
Mailing Address - Country:US
Mailing Address - Phone:772-249-4058
Mailing Address - Fax:
Practice Address - Street 1:698 SW PORT ST LUCIE BLVD STE 107
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-1565
Practice Address - Country:US
Practice Address - Phone:772-249-4058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA54460225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist