MEDICARE: MORENO THERAPY

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	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851916373
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MORENO THERAPY

Provider Business Mailing Address
First Line	:	256 N 115TH ST STE 3
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68154-2558
Country	:	US
Telephone Number	:	402-660-9555
Fax Number	:

Provider Business Practice Location Address
First Line	:	256 N 115TH ST STE 3
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68154-2558
Country	:	US
Telephone Number	:	402-660-9555
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	DOMINIQUE RAY MORENO
Credential	:	LIMHP
Telephone Number	:	402-660-9555

Provider Enumeration Date	:	06/10/2020
Last Update Date	:	11/14/2024

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Directions to “MORENO THERAPY ” Practice Location

Language	Start Address	Practice Location

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