Provider Demographics
NPI:1982204665
Name:MORENO, DIANELYS (RBT)
Entity Type:Individual
Prefix:
First Name:DIANELYS
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 W 76TH ST APT 202
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-5369
Mailing Address - Country:US
Mailing Address - Phone:786-525-3209
Mailing Address - Fax:
Practice Address - Street 1:2811 W 76TH ST APT 202
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33018-5369
Practice Address - Country:US
Practice Address - Phone:786-525-3209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-140682106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-20-140682Medicaid