Provider Demographics
NPI:1730227034
Name:MORENO, EDNA (BS SLP)
Entity type:Individual
Prefix:MRS
First Name:EDNA
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:BS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 E LYNNE LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-5255
Mailing Address - Country:US
Mailing Address - Phone:602-284-1657
Mailing Address - Fax:
Practice Address - Street 1:4301 E LYNNE LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-5255
Practice Address - Country:US
Practice Address - Phone:602-284-1657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL5122235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ134804Medicaid