Healthcare Provider Details

I. General information

NPI: 1558073833
Provider Name (Legal Business Name): JOSEPH MORENO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 S 76TH ST STE 220
MILWAUKEE WI
53214-1599
US

IV. Provider business mailing address

N90W27785 S RED FOX RUN
HARTLAND WI
53029-1165
US

V. Phone/Fax

Practice location:
  • Phone: 718-406-7268
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number134735
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13063
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: