Healthcare Provider Details

I. General information

NPI: 1194949396
Provider Name (Legal Business Name): LUCILA A. MORENO LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LUCILA A. PERALEZ-MORENO L.I.S.W.

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 RALSTON AVE
DEFIANCE OH
43512
US

IV. Provider business mailing address

5700 SOUTHWYCK BLVD
TOLEDO OH
43614-1509
US

V. Phone/Fax

Practice location:
  • Phone: 419-783-6955
  • Fax: 419-291-6436
Mailing address:
  • Phone: 800-288-8325
  • Fax: 419-866-5453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI 0007980
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: