Healthcare Provider Details

I. General information

NPI: 1194222380
Provider Name (Legal Business Name): BRANDON ARTHUR MOAK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2474 E HUNT HWY # 100
SAN TAN VALLEY AZ
85143-5210
US

IV. Provider business mailing address

1365 E ASH RD
SAN TAN VALLEY AZ
85140-3214
US

V. Phone/Fax

Practice location:
  • Phone: 480-784-1514
  • Fax:
Mailing address:
  • Phone: 480-317-2213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC16429
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: