Provider Demographics
NPI:1366813057
Name:MORENO, SUSAN JULIA (PTA)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:JULIA
Last Name:MORENO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 44TH ST
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-8502
Mailing Address - Country:US
Mailing Address - Phone:701-226-2986
Mailing Address - Fax:
Practice Address - Street 1:301 LORRAIN DR
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-0311
Practice Address - Country:US
Practice Address - Phone:701-255-1084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND0379225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant