Healthcare Provider Details

I. General information

NPI: 1861687642
Provider Name (Legal Business Name): DOUG MOSER M.A., L.L.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2007
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 6TH ST
TRAVERSE CITY MI
49684-2345
US

IV. Provider business mailing address

230 W 16TH ST
TRAVERSE CITY MI
49684-4120
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-6461
  • Fax: 231-935-6920
Mailing address:
  • Phone: 231-946-7930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberL1152057
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: