Provider Demographics
NPI:1871190975
Name:MORENO MEDINA, ANIOBYS ERNESTO
Entity Type:Individual
Prefix:
First Name:ANIOBYS
Middle Name:ERNESTO
Last Name:MORENO MEDINA
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 1:1954 COOLIDGE ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-2426
Mailing Address - Country:US
Mailing Address - Phone:786-380-6589
Mailing Address - Fax:
Practice Address - Street 1:1954 COOLIDGE ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-2426
Practice Address - Country:US
Practice Address - Phone:786-380-6589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-120930106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician