Provider Demographics
NPI:1073168217
Name:MOTO, MICHAEL ALEXANDER (MHP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALEXANDER
Last Name:MOTO
Suffix:
Gender:M
Credentials:MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 JACKSON ST STE 119
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-3096
Mailing Address - Country:US
Mailing Address - Phone:318-625-7050
Mailing Address - Fax:318-625-7197
Practice Address - Street 1:3600 JACKSON ST STE 119
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3096
Practice Address - Country:US
Practice Address - Phone:318-625-7050
Practice Address - Fax:318-625-7197
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACIT-5521101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0000OtherNONE