Provider Demographics
NPI:1790098077
Name:MORENO, IDALMIS E (LMHC)
Entity Type:Individual
Prefix:
First Name:IDALMIS
Middle Name:E
Last Name:MORENO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1946 CLYDESDALE DR
Mailing Address - Street 2:
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-3914
Mailing Address - Country:US
Mailing Address - Phone:561-383-9800
Mailing Address - Fax:561-383-9855
Practice Address - Street 1:2840 6TH AVE S
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-4729
Practice Address - Country:US
Practice Address - Phone:561-383-9800
Practice Address - Fax:561-383-9855
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13838101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1790098077Medicaid