Provider Demographics
NPI:1578107967
Name:MORENO, VIVIAN
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 FINLEY RD STE 101
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1394
Mailing Address - Country:US
Mailing Address - Phone:815-469-1500
Mailing Address - Fax:630-919-8132
Practice Address - Street 1:2901 FINLEY RD STE 101
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1394
Practice Address - Country:US
Practice Address - Phone:815-469-1500
Practice Address - Fax:630-919-8132
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-225836103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst