Healthcare Provider Details

I. General information

NPI: 1578107967
Provider Name (Legal Business Name): VIVIAN MORENO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 E ROOSEVELT RD
VILLA PARK IL
60181-3500
US

IV. Provider business mailing address

220 E ROOSEVELT RD
VILLA PARK IL
60181-3500
US

V. Phone/Fax

Practice location:
  • Phone: 630-602-3624
  • Fax: 224-875-3034
Mailing address:
  • Phone: 630-601-8625
  • Fax: 224-875-3034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-225836
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: