Provider Demographics
NPI:1154441335
Name:MORENO, AUDREY (FP)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:FP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6046 E RIVERSIDE ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215
Mailing Address - Country:US
Mailing Address - Phone:480-634-4880
Mailing Address - Fax:
Practice Address - Street 1:6046 E RIVERSIDE ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215
Practice Address - Country:US
Practice Address - Phone:480-634-4880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ188022Medicare ID - Type Unspecified