Provider Demographics
NPI:1154781441
Name:MORENO, LESLIE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-4684
Mailing Address - Country:US
Mailing Address - Phone:626-833-7568
Mailing Address - Fax:
Practice Address - Street 1:1700 LEHMAN RD
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-5246
Practice Address - Country:US
Practice Address - Phone:626-833-7568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT59732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer