Healthcare Provider Details

I. General information

NPI: 1760959399
Provider Name (Legal Business Name): JAMES KIP W MOYER III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2018
Last Update Date: 11/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2695 E INDUSTRIAL DR
FLAGSTAFF AZ
86004-6109
US

IV. Provider business mailing address

2187 N VICKEY ST
FLAGSTAFF AZ
86004-6121
US

V. Phone/Fax

Practice location:
  • Phone: 928-527-1899
  • Fax: 928-714-6480
Mailing address:
  • Phone: 928-527-1899
  • Fax: 928-714-6480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT-15278
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: