Provider Demographics
NPI:1538669122
Name:MORENO, ELSA (OTR)
Entity Type:Individual
Prefix:
First Name:ELSA
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17301 IH-35 N #101
Mailing Address - Street 2:
Mailing Address - City:BUDA
Mailing Address - State:TX
Mailing Address - Zip Code:78610-6418
Mailing Address - Country:US
Mailing Address - Phone:512-994-4115
Mailing Address - Fax:
Practice Address - Street 1:17301 IH-35 N #101
Practice Address - Street 2:
Practice Address - City:BUDA
Practice Address - State:TX
Practice Address - Zip Code:78610-6418
Practice Address - Country:US
Practice Address - Phone:512-994-4115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118368225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty