Provider Demographics
NPI:1538602230
Name:MORENO, NATHANIEL (RBT)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 E SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6674
Mailing Address - Country:US
Mailing Address - Phone:817-442-0222
Mailing Address - Fax:817-442-0223
Practice Address - Street 1:2425 E SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6674
Practice Address - Country:US
Practice Address - Phone:817-442-0222
Practice Address - Fax:817-442-0223
Is Sole Proprietor?:No
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician