Provider Demographics
NPI:1871653394
Name:MORETA, MICKAELLA (PHD)
Entity Type:Individual
Prefix:
First Name:MICKAELLA
Middle Name:
Last Name:MORETA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 VETERANS MEMORIAL HWY
Mailing Address - Street 2:SUITE 260
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-1042
Mailing Address - Country:US
Mailing Address - Phone:631-467-1029
Mailing Address - Fax:631-467-1136
Practice Address - Street 1:3900 VETERANS MEMORIAL HWY
Practice Address - Street 2:SUITE 260
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-1042
Practice Address - Country:US
Practice Address - Phone:631-467-1029
Practice Address - Fax:631-467-1136
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000754-1103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral