Provider Demographics
NPI:1295559516
Name:MORON, SAMANTHA LAYNE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LAYNE
Last Name:MORON
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 1:1011 NE 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-7609
Mailing Address - Country:US
Mailing Address - Phone:305-850-4339
Mailing Address - Fax:
Practice Address - Street 1:7990 SW 117TH AVE STE 215
Practice Address - Street 2:
Practice Address - City:KENDALL
Practice Address - State:FL
Practice Address - Zip Code:33183-4865
Practice Address - Country:US
Practice Address - Phone:786-963-9770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty