Provider Demographics
NPI:1558482588
Name:MORENO, JAMIE LEE (MSCCCSLP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LEE
Last Name:MORENO
Suffix:
Gender:F
Credentials:MSCCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3726 N HONEYLOCUST DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34465-3384
Mailing Address - Country:US
Mailing Address - Phone:352-746-4194
Mailing Address - Fax:
Practice Address - Street 1:7647 W GULF TO LAKE HWY
Practice Address - Street 2:SUITE 4
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-7962
Practice Address - Country:US
Practice Address - Phone:352-795-4181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8521235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist