MEDICARE: ELHAM MOGHADDAM

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	103T00000X	Psychologist	6362009335	MI

General Provider Information

NPI Number	:	1407529654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELHAM MOGHADDAM

Provider Business Mailing Address
First Line	:	363 W BIG BEAVER RD STE 400
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48084-5242
Country	:	US
Telephone Number	:	248-509-7657
Fax Number	:

Provider Business Practice Location Address
First Line	:	363 W BIG BEAVER RD STE 400
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48084-5242
Country	:	US
Telephone Number	:	248-509-7657
Fax Number	:

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

Provider Enumeration Date	:	07/25/2021
Last Update Date	:	07/19/2022

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Directions to “ ELHAM MOGHADDAM ” Practice Location

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