Provider Demographics
NPI:1982150140
Name:MORENO, OMAR (LCP)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1553
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-6009
Mailing Address - Country:US
Mailing Address - Phone:224-432-9196
Mailing Address - Fax:
Practice Address - Street 1:1441 S 61ST CT
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-1049
Practice Address - Country:US
Practice Address - Phone:224-432-9196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2016-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL199960618Medicaid