Provider Demographics
NPI:1730384868
Name:MORENO, ANNGELA DANETTE (BS)
Entity type:Individual
Prefix:MRS
First Name:ANNGELA
Middle Name:DANETTE
Last Name:MORENO
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4436 NW 50TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2212
Mailing Address - Country:US
Mailing Address - Phone:405-742-8404
Mailing Address - Fax:405-372-8529
Practice Address - Street 1:2322 W 7TH AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-1903
Practice Address - Country:US
Practice Address - Phone:405-742-8404
Practice Address - Fax:405-372-8529
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK10Medicare UPIN