Provider Demographics
NPI:1437664257
Name:MORENO, CARLOS EDUARDO (DOT OTR/L)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:EDUARDO
Last Name:MORENO
Suffix:
Gender:M
Credentials:DOT OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 ROSLYN AVE
Mailing Address - Street 2:
Mailing Address - City:GLENSIDE
Mailing Address - State:PA
Mailing Address - Zip Code:19038-3515
Mailing Address - Country:US
Mailing Address - Phone:610-247-9531
Mailing Address - Fax:
Practice Address - Street 1:209 ROSLYN AVE
Practice Address - Street 2:
Practice Address - City:GLENSIDE
Practice Address - State:PA
Practice Address - Zip Code:19038-3515
Practice Address - Country:US
Practice Address - Phone:610-247-9531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC003092L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist