Healthcare Provider Details

I. General information

NPI: 1073420873
Provider Name (Legal Business Name): VICTOR MORENO PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 S 39TH ST
MILWAUKEE WI
53215-4019
US

IV. Provider business mailing address

3300 S 39TH ST
MILWAUKEE WI
53215-4019
US

V. Phone/Fax

Practice location:
  • Phone: 414-902-7889
  • Fax:
Mailing address:
  • Phone: 414-902-7889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: