Provider Demographics
NPI:1104390871
Name:MORENO, MINERVA G (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MINERVA
Middle Name:G
Last Name:MORENO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10841 WATERBRIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-2360
Mailing Address - Country:US
Mailing Address - Phone:469-473-1638
Mailing Address - Fax:
Practice Address - Street 1:8035 E R L THORNTON FWY STE 503
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-7012
Practice Address - Country:US
Practice Address - Phone:469-473-1638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
TX28405101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical