Provider Demographics
NPI:1023552064
Name:MORENO, JAVIER E (OT)
Entity Type:Individual
Prefix:MR
First Name:JAVIER
Middle Name:E
Last Name:MORENO
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 398
Mailing Address - Street 2:216 NORTH 2ND STREET
Mailing Address - City:AMITE
Mailing Address - State:LA
Mailing Address - Zip Code:70422
Mailing Address - Country:US
Mailing Address - Phone:985-748-7878
Mailing Address - Fax:985-748-2837
Practice Address - Street 1:216 NORTH 2ND STREET
Practice Address - Street 2:
Practice Address - City:AMITE
Practice Address - State:LA
Practice Address - Zip Code:70422
Practice Address - Country:US
Practice Address - Phone:985-748-7878
Practice Address - Fax:985-748-2837
Is Sole Proprietor?:No
Enumeration Date:2016-12-09
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.211550225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation