MEDICARE: TASHA MORENO BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	BCBA: 1-13-13886	CO

General Provider Information

NPI Number	:	1093054256
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TASHA MORENO BCBA

Provider Business Mailing Address
First Line	:	3731 6TH AVE STE 100
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-4383
Country	:	US
Telephone Number	:	619-977-7201
Fax Number	:	619-374-7134

Provider Business Practice Location Address
First Line	:	1330 QUAIL LAKE LOOP STE 120
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-4651
Country	:	US
Telephone Number	:	619-977-7201
Fax Number	:	619-374-7134

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2013
Last Update Date	:	09/19/2013

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