MEDICARE: MS. MARY ELLEN MORENO BA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	101YM0800X	FL
2	171M00000X	Case Manager/Care Coordinator	M650540586680	FL

General Provider Information

NPI Number	:	1811248008
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY ELLEN MORENO BA

Provider Business Mailing Address
First Line	:	6266 DUPONT STATION CT E
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-2567
Country	:	US
Telephone Number	:	904-745-0067
Fax Number	:	904-745-1030

Provider Business Practice Location Address
First Line	:	6266 DUPONT STATION CT E
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-2567
Country	:	US
Telephone Number	:	904-745-0067
Fax Number	:	904-745-1030

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2012
Last Update Date	:	08/02/2022

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