Basic Information
| Provider Information | |||||||||
| NPI: | 1639429723 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORENO | ||||||||
| FirstName: | BASILISO | ||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39 CAMBRIDGE TER APT B | ||||||||
| Address2: | |||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076017202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014679524 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9131 QUEENS BLVD STE 618 | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113735543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182750983 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2012 | ||||||||
| LastUpdateDate: | 09/15/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.