1528491834 NPI number — MR. MARCOS MORENO LMSW

Table of content: MR. MARCOS MORENO LMSW (NPI 1528491834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528491834 NPI number — MR. MARCOS MORENO LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORENO
Provider First Name:
MARCOS
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528491834
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5154 N BUCKBOARD PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83713-1871
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-995-3664
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4120 N LINDER RD STE 109
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERIDIAN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83646-5416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-391-4841
Provider Business Practice Location Address Fax Number:
208-391-4966
Provider Enumeration Date:
08/10/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  LMSW-33200 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: LCSW-35672 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)