Healthcare Provider Details

I. General information

NPI: 1497203897
Provider Name (Legal Business Name): JOSE LUIS MORENO PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 UPHAM DR
COLUMBUS OH
43210-1250
US

IV. Provider business mailing address

700 ACKERMAN RD STE 2100
COLUMBUS OH
43202-1559
US

V. Phone/Fax

Practice location:
  • Phone: 614-293-9600
  • Fax: 614-293-1456
Mailing address:
  • Phone: 614-293-9600
  • Fax: 614-293-1456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number7510
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: