Provider Demographics
NPI:1831253129
Name:MORENO, MICHELE LEIGH (PT)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:LEIGH
Last Name:MORENO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 STRADELLA CT
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-4299
Mailing Address - Country:US
Mailing Address - Phone:608-225-2009
Mailing Address - Fax:
Practice Address - Street 1:401 STRADELLA CT
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-4299
Practice Address - Country:US
Practice Address - Phone:608-225-2009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2021-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3038225100000X
COPTL-11520225100000X
WI5284-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36132400Medicaid
000280051Medicare PIN