Provider Demographics
NPI:1013504232
Name:MORENO, MICHELLE (MS, RDT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:MS, RDT
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:FOSTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, RDT
Mailing Address - Street 1:595 SW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-3809
Mailing Address - Country:US
Mailing Address - Phone:786-518-0015
Mailing Address - Fax:
Practice Address - Street 1:595 SW 10TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33130-3809
Practice Address - Country:US
Practice Address - Phone:786-518-0015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY756102X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102X00000XBehavioral Health & Social Service ProvidersPoetry Therapist