Basic Information
| Provider Information | |||||||||
| NPI: | 1053455337 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORENO | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 SAYBROOK RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064574780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606383820 | ||||||||
| FaxNumber: | 8606383840 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 SAYBROOK RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064574780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606383820 | ||||||||
| FaxNumber: | 8606383840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2007 | ||||||||
| LastUpdateDate: | 05/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251G0304X | 4956 | CT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics | 225100000X | 4956 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251H1200X | 4956 | CT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand | 2251P0200X | 4956 | CT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | 2251S0007X | 4956 | CT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 2251X0800X | 4956 | CT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 64-04254 | 01 | CT | UNITED HEALTHCARE | OTHER | 712712 | 01 | CT | CONNECTICARE | OTHER | OV1691 | 01 | CT | HEALTHNET | OTHER | 004175114 | 05 | CT | MEDICAID | A667399 | 01 | CT | OXFORD | OTHER | 080004956CT03 | 01 | CT | ANTHEM BCBS | OTHER | 114175114-00 | 01 | CT | BLUE CARE FAMILY PLAN | OTHER | 3372505 | 01 | CT | AETNA | OTHER |