Provider Demographics
NPI:1730841446
Name:MORENO, SHANNICK ANNAI
Entity type:Individual
Prefix:
First Name:SHANNICK
Middle Name:ANNAI
Last Name:MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13116 SOLAR BAY LN
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-9523
Mailing Address - Country:US
Mailing Address - Phone:951-281-9704
Mailing Address - Fax:
Practice Address - Street 1:13116 SOLAR BAY LN
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394-9523
Practice Address - Country:US
Practice Address - Phone:951-281-9704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-10
Last Update Date:2021-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68742355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant