Healthcare Provider Details

I. General information

NPI: 1295788115
Provider Name (Legal Business Name): CAROL LYNN MORESCO-GONIU PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7733 W BURLEIGH ST
MILWAUKEE WI
53222-5003
US

IV. Provider business mailing address

N33W23374 GREENBRIAR CT
PEWAUKEE WI
53072-5721
US

V. Phone/Fax

Practice location:
  • Phone: 262-347-8848
  • Fax:
Mailing address:
  • Phone: 627-819-8972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number1151-057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: