Healthcare Provider Details

I. General information

NPI: 1629989504
Provider Name (Legal Business Name): LILLIAN MARIE MORENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 SAN RAMON DR
FULLERTON CA
92835-1238
US

IV. Provider business mailing address

2610 ASSOCIATED RD APT A1
FULLERTON CA
92835-3228
US

V. Phone/Fax

Practice location:
  • Phone: 210-668-9444
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number8824
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: