Provider Demographics
NPI:1871309963
Name:MORENO, ALYSSA JADE
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:JADE
Last Name:MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2929 COORS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1173
Mailing Address - Country:US
Mailing Address - Phone:505-788-6770
Mailing Address - Fax:
Practice Address - Street 1:2929 COORS BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-1173
Practice Address - Country:US
Practice Address - Phone:505-788-6770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-04
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM390200000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program