Provider Demographics
NPI:1194490243
Name:MORENO, MICHELLE LYNN (LGSW)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LYNN
Last Name:MORENO
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 60TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-9140
Mailing Address - Country:US
Mailing Address - Phone:320-905-4345
Mailing Address - Fax:507-218-8492
Practice Address - Street 1:2120 60TH AVE NE
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-9140
Practice Address - Country:US
Practice Address - Phone:320-905-4345
Practice Address - Fax:507-218-8492
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MN24899104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health