MEDICARE: MICHAELA MOFFETT

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	104100000X	Social Worker	5477	ND
2	1041C0700X	Clinical Social Worker	5477	ND

General Provider Information

NPI Number	:	1780202515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAELA MOFFETT

Provider Business Mailing Address
First Line	:	4324 UNIVERSITY AVE STE C
Second Line	:
City	:	GRAND FORKS
State	:	ND
Zip	:	58203-1938
Country	:	US
Telephone Number	:	701-775-7725
Fax Number	:

Provider Business Practice Location Address
First Line	:	4324 UNIVERSITY AVE STE C
Second Line	:
City	:	GRAND FORKS
State	:	ND
Zip	:	58203-1938
Country	:	US
Telephone Number	:	701-775-7725
Fax Number	:

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

Provider Enumeration Date	:	07/08/2020
Last Update Date	:	10/10/2024

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