Provider Demographics
NPI:1104216704
Name:MORENO, REBECCA (LCPC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 24TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-5389
Mailing Address - Country:US
Mailing Address - Phone:309-779-3970
Mailing Address - Fax:309-779-2159
Practice Address - Street 1:3919 16TH ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-7217
Practice Address - Country:US
Practice Address - Phone:309-797-6983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-03
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
IL180.008375101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional