Provider Demographics
NPI:1073665709
Name:MORENO, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
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 1:271 CUNNINGHAM LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1915
Mailing Address - Country:US
Mailing Address - Phone:630-529-1683
Mailing Address - Fax:
Practice Address - Street 1:606 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-1934
Practice Address - Country:US
Practice Address - Phone:630-530-8551
Practice Address - Fax:630-530-5909
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist