Provider Demographics
NPI:1316294044
Name:MORENO, LETICIA LORRAINE (MAED, BCBA)
Entity type:Individual
Prefix:MRS
First Name:LETICIA
Middle Name:LORRAINE
Last Name:MORENO
Suffix:
Gender:F
Credentials:MAED, BCBA
Other - Prefix:MS
Other - First Name:LETICIA
Other - Middle Name:LORRAINE
Other - Last Name:DYETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8128 MANDAN TER
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-2638
Mailing Address - Country:US
Mailing Address - Phone:914-494-3187
Mailing Address - Fax:
Practice Address - Street 1:8128 MANDAN TER
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2638
Practice Address - Country:US
Practice Address - Phone:914-494-3187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
NY646528121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174400000XOther Service ProvidersSpecialist