Provider Demographics
NPI:1396327805
Name:MORENO, RACHEL ELIZABETH
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:ELIZABETH
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 1:13296 FM 16 E
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:TX
Mailing Address - Zip Code:75792-5308
Mailing Address - Country:US
Mailing Address - Phone:903-570-2814
Mailing Address - Fax:
Practice Address - Street 1:8333 COUNTY ROAD 381
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75708-5733
Practice Address - Country:US
Practice Address - Phone:903-570-2814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No171W00000XOther Service ProvidersContractor
No171WH0202XOther Service ProvidersContractorHome Modifications