Basic Information
| Provider Information | |||||||||
| NPI: | 1023172186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORENO | ||||||||
| FirstName: | TRICIA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | AUD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 58058 WINDSOR AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466199407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742981075 | ||||||||
| FaxNumber: | 5742379383 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 N EDDY ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466172808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742379200 | ||||||||
| FaxNumber: | 5742379383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 11/05/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | IN | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
No ID Information.