Provider Demographics
NPI:1073665931
Name:MORENO, RICHARD (PHD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S BRADLEY ST
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75069-4509
Mailing Address - Country:US
Mailing Address - Phone:972-673-4111
Mailing Address - Fax:972-578-8397
Practice Address - Street 1:1721 W PLANO PKWY
Practice Address - Street 2:SUITE 107
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-8634
Practice Address - Country:US
Practice Address - Phone:972-673-4111
Practice Address - Fax:972-578-8397
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24453103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0022LVOtherBLUE CROSS BLUE SHIELD
TX611422Medicare ID - Type Unspecified
TX0022LVOtherBLUE CROSS BLUE SHIELD