Provider Demographics
NPI:1154666147
Name:MORENO, KAREN (LCDC)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 STAGGERBRUSH RD APT 214
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-1039
Mailing Address - Country:US
Mailing Address - Phone:512-919-0126
Mailing Address - Fax:
Practice Address - Street 1:8402 CROSS PARK DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78754-4595
Practice Address - Country:US
Practice Address - Phone:512-697-8573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8050324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8050OtherLCDC