Healthcare Provider Details

I. General information

NPI: 1366788325
Provider Name (Legal Business Name): LINNEA MORENO BSW AA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2012
Last Update Date: 12/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 HUNTER ST
ESPANOLA NM
87532-2655
US

IV. Provider business mailing address

404 HUNTER STREET
ESPANOLA NM
87532
US

V. Phone/Fax

Practice location:
  • Phone: 505-629-1813
  • Fax: 505-747-0421
Mailing address:
  • Phone: 505-629-1813
  • Fax: 505-747-0421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: