Provider Demographics
NPI:1396407052
Name:MORENO, DANIELA ARLETTE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DANIELA
Middle Name:ARLETTE
Last Name:MORENO
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71314 EMBASSY RD
Mailing Address - Street 2:
Mailing Address - City:EDWARDSBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49112-9121
Mailing Address - Country:US
Mailing Address - Phone:269-252-8777
Mailing Address - Fax:
Practice Address - Street 1:71314 EMBASSY RD
Practice Address - Street 2:
Practice Address - City:EDWARDSBURG
Practice Address - State:MI
Practice Address - Zip Code:49112-9121
Practice Address - Country:US
Practice Address - Phone:269-252-8777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22007648A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN22007648AOtherSPEECH LANGUAGE PATHOLOGY LICENSE