Healthcare Provider Details

I. General information

NPI: 1497916266
Provider Name (Legal Business Name): BERTA MOYANO RODRIGUEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 MADRID ST
CORAL GABLES FL
33134-2233
US

IV. Provider business mailing address

1503 MADRID ST
CORAL GABLES FL
33134-2233
US

V. Phone/Fax

Practice location:
  • Phone: 305-448-8463
  • Fax: 305-448-8463
Mailing address:
  • Phone: 305-448-8463
  • Fax: 305-448-8463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW8919
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: