Healthcare Provider Details

I. General information

NPI: 1053325571
Provider Name (Legal Business Name): MADELEINE RACHELLE MORENO MSN, PMHNP- BC (CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELLEY MORENO MSN, PMHNP- BC

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 PETER BRYCE BLVD
TUSCALOOSA AL
35401-7456
US

IV. Provider business mailing address

PO BOX 870360
TUSCALOOSA AL
35487-5309
US

V. Phone/Fax

Practice location:
  • Phone: 205-348-6262
  • Fax:
Mailing address:
  • Phone: 205-348-6262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number1-052771
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number1052771
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: