Healthcare Provider Details

I. General information

NPI: 1275502189
Provider Name (Legal Business Name): PATRICIA C MOISAN THOMAS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 UNION ST STE 101
LAFAYETTE IN
47904-3432
US

IV. Provider business mailing address

PO BOX 4699
LAFAYETTE IN
47903-4699
US

V. Phone/Fax

Practice location:
  • Phone: 765-449-8286
  • Fax: 765-449-0445
Mailing address:
  • Phone: 765-449-2732
  • Fax: 765-449-1196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20040188A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20040188A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: