Provider Demographics
NPI:1316312325
Name:MORENO, STEPHANIE (LLP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:376 E APPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-3466
Mailing Address - Country:US
Mailing Address - Phone:231-724-6050
Mailing Address - Fax:231-724-6066
Practice Address - Street 1:376 E APPLE AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-3466
Practice Address - Country:US
Practice Address - Phone:616-742-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-02
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016365103TC1900X
MI6361003075103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling