Healthcare Provider Details

I. General information

NPI: 1639676802
Provider Name (Legal Business Name): LESLEY MORENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2675 HORSESHOE DR S STE 404
NAPLES FL
34104-6155
US

IV. Provider business mailing address

2535 SW 32ND ST
CAPE CORAL FL
33914-4902
US

V. Phone/Fax

Practice location:
  • Phone: 800-217-9289
  • Fax:
Mailing address:
  • Phone: 239-233-6630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: