Provider Demographics
NPI:1598416760
Name:MORENO, TOM ANTHONY (OTR/L)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:ANTHONY
Last Name:MORENO
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7575 LINDA VISTA RD APT 40
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-5322
Mailing Address - Country:US
Mailing Address - Phone:559-761-2138
Mailing Address - Fax:
Practice Address - Street 1:7575 LINDA VISTA RD APT 40
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-5322
Practice Address - Country:US
Practice Address - Phone:559-761-2138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT23138225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist