Provider Demographics
NPI:1972321446
Name:MORENO, SYDNEY (PLPC)
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:SYDNEY
Other - Middle Name:
Other - Last Name:DAUGHERTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PLPC
Mailing Address - Street 1:4142 KEATON CROSSING BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-8406
Mailing Address - Country:US
Mailing Address - Phone:636-300-9333
Mailing Address - Fax:
Practice Address - Street 1:4142 KEATON CROSSING BLVD STE 101
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-8406
Practice Address - Country:US
Practice Address - Phone:636-300-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO202439503101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health