Provider Demographics
NPI:1376697680
Name:TODOROVA-MORENO, ILINA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ILINA
Middle Name:
Last Name:TODOROVA-MORENO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3615 MORGANFORD RD
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-1612
Mailing Address - Country:US
Mailing Address - Phone:314-664-0835
Mailing Address - Fax:314-664-0836
Practice Address - Street 1:3615 MORGANFORD RD
Practice Address - Street 2:1ST FLOOR
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-1612
Practice Address - Country:US
Practice Address - Phone:314-664-0835
Practice Address - Fax:314-664-0836
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002021881103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO496014614Medicaid
MO000021811Medicare ID - Type UnspecifiedPSYCHOLOGIST