Provider Demographics
NPI:1790198463
Name:MICKAELLA MORETA CORP
Entity Type:Organization
Organization Name:MICKAELLA MORETA CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICKAELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORETA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:941-351-2221
Mailing Address - Street 1:2401 UNIVERSITY PKWY BLDG 1
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-2893
Mailing Address - Country:US
Mailing Address - Phone:941-351-2221
Mailing Address - Fax:941-761-6903
Practice Address - Street 1:2401 UNIVERSITY PKWY BLDG 1
Practice Address - Street 2:SUITE 203
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-2893
Practice Address - Country:US
Practice Address - Phone:941-351-2221
Practice Address - Fax:941-761-6903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-10
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPPY185103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty