=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194557991
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANTIAGO MORENO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2024
-----------------------------------------------------
Last Update Date | 08/11/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25031 WESTHEIMER PKWY STE 960
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77494-7317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 979-627-8138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4218 MAPLE GLEN DR
-----------------------------------------------------
City | FULSHEAR
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77441-2291
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 346-667-7363
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------