Healthcare Provider Details

I. General information

NPI: 1902568173
Provider Name (Legal Business Name): OCTAVIO MORENO-LOMELI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2021
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 N 4TH ST
BROOKLYN NY
11249-3296
US

IV. Provider business mailing address

134 N 4TH ST
BROOKLYN NY
11249-3296
US

V. Phone/Fax

Practice location:
  • Phone: 646-450-7748
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number096935
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: