MEDICARE: DR. DESIRAE ANGELA MORENO LP

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	103TC0700X	Clinical Psychologist	1341	KS
2	103TC0700X	Clinical Psychologist	2090	KS
3	103TC0700X	Clinical Psychologist	2287	KS

General Provider Information

NPI Number	:	1326273426
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DESIRAE ANGELA MORENO LP

Provider Business Mailing Address
First Line	:	14508 W PRICE ST
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67235-1600
Country	:	US
Telephone Number	:	316-617-0357
Fax Number	:

Provider Business Practice Location Address
First Line	:	121 S WHITTIER RD
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67207-1064
Country	:	US
Telephone Number	:	316-617-0357
Fax Number	:

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

Provider Enumeration Date	:	05/19/2009
Last Update Date	:	12/25/2022

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