Provider Demographics
NPI:1205110186
Name:MORENO, LANIE R (PT, DPT)
Entity type:Individual
Prefix:MRS
First Name:LANIE
Middle Name:R
Last Name:MORENO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:MISS
Other - First Name:LANIE
Other - Middle Name:R
Other - Last Name:FRANKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:850 BROOKFOREST AVE UNIT L
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60404-8516
Mailing Address - Country:US
Mailing Address - Phone:815-773-9000
Mailing Address - Fax:
Practice Address - Street 1:850 BROOKFOREST AVE UNIT L
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60404
Practice Address - Country:US
Practice Address - Phone:815-773-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37562225100000X
225100000X
IL070018759225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist