Provider Demographics
NPI:1740917335
Name:MORENO, BEVERLY (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 CABIN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238-2701
Mailing Address - Country:US
Mailing Address - Phone:956-639-6593
Mailing Address - Fax:
Practice Address - Street 1:5111 USAA BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-5010
Practice Address - Country:US
Practice Address - Phone:210-397-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111750235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111750OtherTDLR SLP LICENSE
14225877OtherASHA CCC-SLP CERTIFICATION