Healthcare Provider Details

I. General information

NPI: 1487768982
Provider Name (Legal Business Name): MATT ALAN MOORADIAN PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2006
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

3513 42ND ST
HIGHLAND IN
46322-3126
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-3101
  • Fax: 219-836-3102
Mailing address:
  • Phone: 219-836-3101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20040803A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071-004894
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: