Provider Demographics
NPI:1740781079
Name:MORENO, VICKI
Entity Type:Individual
Prefix:
First Name:VICKI
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 1:1321 MURFREESBORO PIKE STE 410
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37217-2626
Mailing Address - Country:US
Mailing Address - Phone:615-361-4000
Mailing Address - Fax:
Practice Address - Street 1:820 DUKE AVE STE A
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-2684
Practice Address - Country:US
Practice Address - Phone:478-225-3380
Practice Address - Fax:615-815-1946
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12041369103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst