Healthcare Provider Details

I. General information

NPI: 1447766613
Provider Name (Legal Business Name): WILLLIAM JOSEPH MOORMAN M.DIV., MS, PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2017
Last Update Date: 12/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 PARK AVE STE 102
BALTIMORE MD
21201-4572
US

IV. Provider business mailing address

110 E MELROSE AVE
BALTIMORE MD
21212-2942
US

V. Phone/Fax

Practice location:
  • Phone: 410-777-8130
  • Fax:
Mailing address:
  • Phone: 410-227-0225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number1263
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1263
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: