Healthcare Provider Details

I. General information

NPI: 1083680987
Provider Name (Legal Business Name): CARL STEPHEN MOISOFF PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 BROADWAY ST STE A
MERRILLVILLE IN
46410
US

IV. Provider business mailing address

9910 ARTHUR COURT
CROWN POINT IN
46307-2357
US

V. Phone/Fax

Practice location:
  • Phone: 800-648-7608
  • Fax: 219-736-9456
Mailing address:
  • Phone: 219-662-0362
  • Fax: 219-736-9456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20040404A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: