Provider Demographics
NPI:1326273426
Name:MORENO, DESIRAE ANGELA (LP)
Entity Type:Individual
Prefix:DR
First Name:DESIRAE
Middle Name:ANGELA
Last Name:MORENO
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:DESIRAE
Other - Middle Name:ANGELA
Other - Last Name:MCKENZIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14508 W PRICE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67235-1600
Mailing Address - Country:US
Mailing Address - Phone:316-617-0357
Mailing Address - Fax:
Practice Address - Street 1:121 S WHITTIER RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-1064
Practice Address - Country:US
Practice Address - Phone:316-617-0357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2022-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1341103TC0700X
KS2090103TC0700X
KS2287103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical