Provider Demographics
NPI:1033550025
Name:MORENO, PAOLA A
Entity type:Individual
Prefix:
First Name:PAOLA
Middle Name:A
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 1:1305 MIDDLE COUNTRY RD STE 11
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2554
Mailing Address - Country:US
Mailing Address - Phone:631-219-6987
Mailing Address - Fax:
Practice Address - Street 1:1305 MIDDLE COUNTRY RD STE 11
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-2554
Practice Address - Country:US
Practice Address - Phone:631-219-6987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020100225700000X
NY005115171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty