MEDICARE: BRANDON ARTHUR MOAK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPC16429	AZ

General Provider Information

NPI Number	:	1194222380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDON ARTHUR MOAK

Provider Business Mailing Address
First Line	:	1365 E ASH RD
Second Line	:
City	:	SAN TAN VALLEY
State	:	AZ
Zip	:	85140-3214
Country	:	US
Telephone Number	:	480-317-2213
Fax Number	:

Provider Business Practice Location Address
First Line	:	2474 E HUNT HWY # 100
Second Line	:
City	:	SAN TAN VALLEY
State	:	AZ
Zip	:	85143-5210
Country	:	US
Telephone Number	:	480-784-1514
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2018
Last Update Date	:	04/12/2018

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Directions to “ BRANDON ARTHUR MOAK ” Practice Location

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