MEDICARE: DR. SKYE PORTER MOFFITT PH.D.

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	103TC0700X	Clinical Psychologist	32837	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0065MX	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1801945415
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SKYE PORTER MOFFITT PH.D.

Provider Business Mailing Address
First Line	:	6350 LYNDON B JOHNSON FWY
Second Line	:	SUITE 151
City	:	DALLAS
State	:	TX
Zip	:	75240-6403
Country	:	US
Telephone Number	:	214-549-8783
Fax Number	:	972-392-9695

Provider Business Practice Location Address
First Line	:	6350 LYNDON B JOHNSON FWY
Second Line	:	SUITE 151
City	:	DALLAS
State	:	TX
Zip	:	75240-6403
Country	:	US
Telephone Number	:	214-549-8783
Fax Number	:	972-392-9695

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

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	07/08/2007

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