Provider Demographics
NPI:1811248008
Name:MORENO, MARY ELLEN (BA)
Entity type:Individual
Prefix:MS
First Name:MARY ELLEN
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6266 DUPONT STATION CT E
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2567
Mailing Address - Country:US
Mailing Address - Phone:904-745-0067
Mailing Address - Fax:904-745-1030
Practice Address - Street 1:6266 DUPONT STATION CT E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2567
Practice Address - Country:US
Practice Address - Phone:904-745-0067
Practice Address - Fax:904-745-1030
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-27
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X101YM0800X
FLM650540586680171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator