Provider Demographics
NPI:1649889510
Name:MORENO, ALEXIS OLIVIA
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:OLIVIA
Last Name:MORENO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1816 GALAS CT
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95358-7136
Mailing Address - Country:US
Mailing Address - Phone:209-408-7886
Mailing Address - Fax:
Practice Address - Street 1:1849 WILLOW PASS RD STE 420
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2524
Practice Address - Country:US
Practice Address - Phone:925-672-9440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19352235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist