Provider Demographics
NPI:1790238665
Name:MORENO, DOMINIQUE RAY (PLMHP)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:RAY
Last Name:MORENO
Suffix:
Gender:F
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5217 S 28TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68107-3402
Mailing Address - Country:US
Mailing Address - Phone:405-715-5459
Mailing Address - Fax:402-715-5452
Practice Address - Street 1:5217 S 28TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68107-3402
Practice Address - Country:US
Practice Address - Phone:405-715-5459
Practice Address - Fax:402-715-5452
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-27
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10926101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health