Provider Demographics
NPI:1356978118
Name:VANDEVELDE MORENO AND ASSOCIATES, LLC
Entity type:Organization
Organization Name:VANDEVELDE MORENO AND ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MARRIAGE AND FAMILY THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDEVELDE MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:229-392-5273
Mailing Address - Street 1:PO BOX 1089
Mailing Address - Street 2:
Mailing Address - City:OMEGA
Mailing Address - State:GA
Mailing Address - Zip Code:31775-1089
Mailing Address - Country:US
Mailing Address - Phone:229-392-5273
Mailing Address - Fax:
Practice Address - Street 1:601 VIRGINIA AVE N STE 1
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-4268
Practice Address - Country:US
Practice Address - Phone:229-396-5507
Practice Address - Fax:229-396-5093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-23
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty