Provider Demographics
NPI:1255104436
Name:MORENO BORGES, ODALYS
Entity type:Individual
Prefix:
First Name:ODALYS
Middle Name:
Last Name:MORENO BORGES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 W 56TH ST APT 312
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-2036
Mailing Address - Country:US
Mailing Address - Phone:786-520-7067
Mailing Address - Fax:
Practice Address - Street 1:1675 W 56TH ST APT 312
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-2036
Practice Address - Country:US
Practice Address - Phone:786-520-7067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-304352106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty