Provider Demographics
NPI:1013043512
Name:MORENO, GRISEL (OTR)
Entity Type:Individual
Prefix:MS
First Name:GRISEL
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:379 PIPE STAVE HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-1332
Mailing Address - Country:US
Mailing Address - Phone:631-474-7843
Mailing Address - Fax:
Practice Address - Street 1:14 RESEARCH WAY
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3453
Practice Address - Country:US
Practice Address - Phone:631-331-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005057225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist