Provider Demographics
NPI:1497582431
Name:MORENO-BOUTON, DANA L (LMSW)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:L
Last Name:MORENO-BOUTON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 PORT WATSON ST APT 224
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-3168
Mailing Address - Country:US
Mailing Address - Phone:718-440-0942
Mailing Address - Fax:
Practice Address - Street 1:783 CHENANGO ST STE D
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-1870
Practice Address - Country:US
Practice Address - Phone:718-440-0942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY118316104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker