MEDICARE: ANITA MORENO LISW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	I7599	OH
2	1041C0700X	Clinical Social Worker	SW16286	FL

General Provider Information

NPI Number	:	1649309006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANITA MORENO LISW

Provider Business Mailing Address
First Line	:	12724 GRAN BAY PKWY W STE 410
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-9486
Country	:	US
Telephone Number	:	904-337-9003
Fax Number	:	904-485-8704

Provider Business Practice Location Address
First Line	:	12724 GRAN BAY PKWY W STE 410
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-9486
Country	:	US
Telephone Number	:	904-337-9003
Fax Number	:	904-485-8704

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2007
Last Update Date	:	02/26/2020

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Directions to “ ANITA MORENO LISW” Practice Location

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