Healthcare Provider Details

I. General information

NPI: 1194490243
Provider Name (Legal Business Name): MICHELLE LYNN MORENO LGSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 04/15/2024
Certification Date: 04/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 60TH AVE NE
WILLMAR MN
56201-9140
US

IV. Provider business mailing address

2120 60TH AVE NE
WILLMAR MN
56201-9140
US

V. Phone/Fax

Practice location:
  • Phone: 320-905-4345
  • Fax: 507-218-8492
Mailing address:
  • Phone: 320-905-4345
  • Fax: 507-218-8492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number24899
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: