Provider Demographics
NPI:1659828903
Name:MORENO, NAOMI
Entity Type:Individual
Prefix:
First Name:NAOMI
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 1:1208 MINTCREST DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-6287
Mailing Address - Country:US
Mailing Address - Phone:574-238-6698
Mailing Address - Fax:
Practice Address - Street 1:1208 MINTCREST DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6287
Practice Address - Country:US
Practice Address - Phone:574-238-6698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-03
Last Update Date:2016-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35801174442255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer