Provider Demographics
NPI:1467578112
Name:MORENO, KASEY M (DPT)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:M
Last Name:MORENO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KASEY
Other - Middle Name:M
Other - Last Name:MCLEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10078 LAPEER RD STE B
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-9031
Practice Address - Country:US
Practice Address - Phone:810-653-6200
Practice Address - Fax:810-653-6226
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013219225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N45090021Medicare PIN