Provider Demographics
NPI:1366735938
Name:MORENO, TERA CONERLY (PT)
Entity type:Individual
Prefix:MRS
First Name:TERA
Middle Name:CONERLY
Last Name:MORENO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39336 OAKLYN DR
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-7094
Mailing Address - Country:US
Mailing Address - Phone:985-507-6349
Mailing Address - Fax:
Practice Address - Street 1:39336 OAKLYN DR
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-7094
Practice Address - Country:US
Practice Address - Phone:985-507-6349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA02657174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1479373Medicaid