Provider Demographics
NPI:1023172186
Name:MORENO, TRICIA L (AUD)
Entity type:Individual
Prefix:
First Name:TRICIA
Middle Name:L
Last Name:MORENO
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58058 WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46619-9407
Mailing Address - Country:US
Mailing Address - Phone:574-298-1075
Mailing Address - Fax:574-237-9383
Practice Address - Street 1:100 NAVARRE PL STE 4460
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1168
Practice Address - Country:US
Practice Address - Phone:574-235-1010
Practice Address - Fax:574-232-2064
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN237600000X
IN23002162A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200133740Medicaid
IN000000085508OtherANTHEM PIN
IN200133740Medicaid