Healthcare Provider Details

I. General information

NPI: 1497774244
Provider Name (Legal Business Name): MARK MOSKAL LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 05/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12851 GRAND RIVER RD
BRIGHTON MI
48116-8506
US

IV. Provider business mailing address

12851 GRAND RIVER RD
BRIGHTON MI
48116-8506
US

V. Phone/Fax

Practice location:
  • Phone: 810-227-1211
  • Fax: 810-220-5509
Mailing address:
  • Phone: 810-227-1211
  • Fax: 810-220-5509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401009003
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: