Provider Demographics
NPI:1295999894
Name:MOMAN, DALENA S
Entity type:Individual
Prefix:
First Name:DALENA
Middle Name:S
Last Name:MOMAN
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 1:1022 ROYCE AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-4993
Mailing Address - Country:US
Mailing Address - Phone:269-343-8480
Mailing Address - Fax:269-343-5773
Practice Address - Street 1:1022 ROYCE AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-4993
Practice Address - Country:US
Practice Address - Phone:269-343-8480
Practice Address - Fax:269-343-5773
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-12
Last Update Date:2008-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF390069743320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities