MEDICARE: NEGIN MOALLEM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LPC.0015037	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	196553M002	OTHER	CO	ANTHEM BLUE CROSS BLUESHIELD

General Provider Information

NPI Number	:	1710540414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NEGIN MOALLEM

Provider Business Mailing Address
First Line	:	8614 E DARTMOUTH AVE
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80231-4204
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8614 E DARTMOUTH AVE
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80231-4204
Country	:	US
Telephone Number	:	303-887-1183
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2019
Last Update Date	:	04/17/2019

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