Provider Demographics
NPI:1912334046
Name:MORENO, LUPITA ADALI (MA CCC/SLP)
Entity Type:Individual
Prefix:
First Name:LUPITA
Middle Name:ADALI
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 1:1500 SW 104TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-7661
Mailing Address - Country:US
Mailing Address - Phone:405-395-7203
Mailing Address - Fax:
Practice Address - Street 1:1500 SW 104TH ST STE 2
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7661
Practice Address - Country:US
Practice Address - Phone:405-395-7203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4150235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist