Provider Demographics
NPI:1548721467
Name:MOREDO ORTEGA, LEYANIS
Entity type:Individual
Prefix:
First Name:LEYANIS
Middle Name:
Last Name:MOREDO ORTEGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LEYANIS
Other - Middle Name:
Other - Last Name:MOREDO ORTEGA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RBT-19-81912
Mailing Address - Street 1:2230 LAKE WORTH RD APT 111
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-3206
Mailing Address - Country:US
Mailing Address - Phone:786-440-1871
Mailing Address - Fax:
Practice Address - Street 1:2230 LAKE WORTH RD APT 111
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-3206
Practice Address - Country:US
Practice Address - Phone:786-440-1871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-81912106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician