=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295788115
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROL LYNN MORESCO-GONIU PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2006
-----------------------------------------------------
Last Update Date | 03/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7733 W BURLEIGH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53222-5003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-347-8848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | N33W23374 GREENBRIAR CT
-----------------------------------------------------
City | PEWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53072-5721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 627-819-8972
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TA0700X
-----------------------------------------------------
Taxonomy Name | Adult Development & Aging Psychologist
-----------------------------------------------------
License Number | 1151-057
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------