Healthcare Provider Details

I. General information

NPI: 1063862258
Provider Name (Legal Business Name): MICHAEL STEVEN MOATES EDD, LP, LBA, QBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 10/25/2023
Certification Date: 10/24/2023
Deactivation Date: 01/23/2022
Reactivation Date: 04/14/2022

III. Provider practice location address

5764 N ORANGE BLOSSOM TRL
ORLANDO FL
32810
US

IV. Provider business mailing address

2700 COLORADO BLVD APT 1526
DENTON TX
76210-6839
US

V. Phone/Fax

Practice location:
  • Phone: 179-349-5008
  • Fax:
Mailing address:
  • Phone: 817-999-7534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 6
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberTPPY1662
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number StateNULL
# 10
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0133002387
License Number StateVA
# 11
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: