Provider Demographics
NPI:1407119993
Name:MORENO, LISA KATHLEEN (OTR/L, CHT, PAMS)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:KATHLEEN
Last Name:MORENO
Suffix:
Gender:F
Credentials:OTR/L, CHT, PAMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 TANK FARM RD.
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401
Mailing Address - Country:US
Mailing Address - Phone:905-545-8699
Mailing Address - Fax:
Practice Address - Street 1:187 TANK FARM RD
Practice Address - Street 2:SUITE 220
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7081
Practice Address - Country:US
Practice Address - Phone:905-545-8699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2565225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist