Provider Demographics
NPI:1558765644
Name:MORENO, GINA (DPT, PT)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 SE 16TH PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-3819
Mailing Address - Country:US
Mailing Address - Phone:239-772-2363
Mailing Address - Fax:239-772-2365
Practice Address - Street 1:1402 SE 16TH PL
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-3819
Practice Address - Country:US
Practice Address - Phone:239-772-2363
Practice Address - Fax:239-772-2365
Is Sole Proprietor?:No
Enumeration Date:2014-10-17
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL29482225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist