Provider Demographics
NPI:1669605333
Name:MORENO, MYLENE A (PT)
Entity type:Individual
Prefix:MISS
First Name:MYLENE
Middle Name:A
Last Name:MORENO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 WEST AVE APT 1911
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-0908
Mailing Address - Country:US
Mailing Address - Phone:305-604-8051
Mailing Address - Fax:305-604-8051
Practice Address - Street 1:1330 WEST AVE APT 1911
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-0908
Practice Address - Country:US
Practice Address - Phone:305-604-8051
Practice Address - Fax:305-604-8051
Is Sole Proprietor?:No
Enumeration Date:2009-08-28
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16672174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist