Provider Demographics
NPI:1164877239
Name:MORENO, DORENE (MA 60429730)
Entity Type:Individual
Prefix:
First Name:DORENE
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:MA 60429730
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E 11TH ST
Mailing Address - Street 2:LL1
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3200
Mailing Address - Country:US
Mailing Address - Phone:360-905-0101
Mailing Address - Fax:
Practice Address - Street 1:205 E 11TH ST
Practice Address - Street 2:LL1
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-3200
Practice Address - Country:US
Practice Address - Phone:360-905-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-26
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60429730225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist