Healthcare Provider Details

I. General information

NPI: 1780418954
Provider Name (Legal Business Name): HAZEL M. KELLY MORENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2024
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 2 INT 417 EDIFICIO PUCHO POOL LOCAL 202 BASE 16
AGUADA PR
00602-9998
US

IV. Provider business mailing address

CARRETERA 2 INT. 417 , EDIFICIO PONCHO POOL CENTER LOCAL 202
AGUADA PR
00602-9998
US

V. Phone/Fax

Practice location:
  • Phone: 787-973-9686
  • Fax:
Mailing address:
  • Phone: 787-973-9686
  • Fax: 999-999-9999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6374
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: