Provider Demographics
NPI:1376887802
Name:MORENO, DONNA CARLISLE (LPTA)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:CARLISLE
Last Name:MORENO
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 LAWRENCE ST
Mailing Address - Street 2:
Mailing Address - City:IRONDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35210-1401
Mailing Address - Country:US
Mailing Address - Phone:205-613-6570
Mailing Address - Fax:
Practice Address - Street 1:1313 LAWRENCE ST
Practice Address - Street 2:
Practice Address - City:IRONDALE
Practice Address - State:AL
Practice Address - Zip Code:35210-1401
Practice Address - Country:US
Practice Address - Phone:205-613-6570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTA585225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant