Provider Demographics
NPI:1720802507
Name:MORENO, ASHANTI
Entity type:Individual
Prefix:MS
First Name:ASHANTI
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 ASHBURNHAM ST
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-2803
Mailing Address - Country:US
Mailing Address - Phone:413-404-3951
Mailing Address - Fax:
Practice Address - Street 1:19 ASHBURNHAM ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-2803
Practice Address - Country:US
Practice Address - Phone:413-404-3951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16258225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist