Provider Demographics
NPI:1184595761
Name:MORENO, EMILY (R-DMT)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:R-DMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MANNING AVE
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:NJ
Mailing Address - Zip Code:07405-1136
Mailing Address - Country:US
Mailing Address - Phone:973-271-9402
Mailing Address - Fax:
Practice Address - Street 1:4456 AMBOY RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-3897
Practice Address - Country:US
Practice Address - Phone:718-967-0490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-16
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health