Provider Demographics
NPI:1134810039
Name:MORENO BALLESTEROS, RICARDO
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:MORENO BALLESTEROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 E 3RD ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-6219
Mailing Address - Country:US
Mailing Address - Phone:786-973-4076
Mailing Address - Fax:
Practice Address - Street 1:229 E 3RD ST UNIT 2
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-6219
Practice Address - Country:US
Practice Address - Phone:786-973-4076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-273362106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician