Provider Demographics
NPI:1194949396
Name:MORENO, LUCILA A (LISW-S)
Entity type:Individual
Prefix:
First Name:LUCILA
Middle Name:A
Last Name:MORENO
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:LUCILA
Other - Middle Name:A
Other - Last Name:PERALEZ-MORENO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISW
Mailing Address - Street 1:5700 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1509
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:1200 RALSTON AVE
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512
Practice Address - Country:US
Practice Address - Phone:419-783-6955
Practice Address - Fax:419-291-6436
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI 00079801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
234966-000OtherMAGELLAN HEALTH SERVICES