Provider Demographics
NPI:1326217662
Name:MORENO, KATHLEEN ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ANN
Last Name:MORENO
Suffix:
Gender:F
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:10850 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 1150
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4305
Mailing Address - Country:US
Mailing Address - Phone:310-446-4604
Mailing Address - Fax:310-470-7110
Practice Address - Street 1:10850 WILSHIRE BLVD
Practice Address - Street 2:SUITE 1150
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-4305
Practice Address - Country:US
Practice Address - Phone:310-446-4604
Practice Address - Fax:310-470-7110
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-20
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG771092084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG77109Medicare UPIN