Healthcare Provider Details

I. General information

NPI: 1154666147
Provider Name (Legal Business Name): KAREN MORENO LCDC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2012
Last Update Date: 12/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8402 CROSS PARK DR
AUSTIN TX
78754-4595
US

IV. Provider business mailing address

4701 STAGGERBRUSH RD APT 214
AUSTIN TX
78749-1039
US

V. Phone/Fax

Practice location:
  • Phone: 512-697-8573
  • Fax:
Mailing address:
  • Phone: 512-919-0126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number8050
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: