Healthcare Provider Details

I. General information

NPI: 1275794869
Provider Name (Legal Business Name): MATT MOORADIAN,PSY,D. P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 03/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9245 CALUMET AVE SUITE 102
MUNSTER IN
46321-2821
US

IV. Provider business mailing address

9245 CALUMET AVE SUITE 102
MUNSTER IN
46321-2821
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-3101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20040803
License Number StateIN

VIII. Authorized Official

Name: DR. MATT MOORADIAN
Title or Position: PSYCHOLOGIST
Credential:
Phone: 219-836-3101