Healthcare Provider Details

I. General information

NPI: 1356646046
Provider Name (Legal Business Name): LEIF JOHN MOA-ANDERSON MA, LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2011
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 NE 129TH ST SUITE 101
VANCOUVER WA
98686-3268
US

IV. Provider business mailing address

PO BOX 82819
PORTLAND OR
97282-0819
US

V. Phone/Fax

Practice location:
  • Phone: 360-574-0303
  • Fax: 360-574-9311
Mailing address:
  • Phone: 360-574-9303
  • Fax: 360-574-9311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC60189409
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG60434410
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60620675
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: