Provider Demographics
NPI:1568668093
Name:MORENO, DARBY L (LCSW)
Entity type:Individual
Prefix:
First Name:DARBY
Middle Name:L
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 1:3030 PECKENS RD
Mailing Address - Street 2:
Mailing Address - City:HONOR
Mailing Address - State:MI
Mailing Address - Zip Code:49640-9536
Mailing Address - Country:US
Mailing Address - Phone:231-325-5039
Mailing Address - Fax:
Practice Address - Street 1:6051 FRANKFORT HWY
Practice Address - Street 2:SUITE 200
Practice Address - City:BENZONIA
Practice Address - State:MI
Practice Address - Zip Code:49616-9558
Practice Address - Country:US
Practice Address - Phone:877-398-2013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010329051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801032905OtherMICHIGAN STATE LICENSE
MIE16035014Medicare PIN
MI6801032905OtherMICHIGAN STATE LICENSE