Provider Demographics
NPI:1083680987
Name:MOISOFF, CARL STEPHEN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:STEPHEN
Last Name:MOISOFF
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9910 ARTHUR COURT
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-2357
Mailing Address - Country:US
Mailing Address - Phone:219-662-0362
Mailing Address - Fax:219-736-9456
Practice Address - Street 1:8500 BROADWAY ST
Practice Address - Street 2:STE A
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410
Practice Address - Country:US
Practice Address - Phone:800-648-7608
Practice Address - Fax:219-736-9456
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040404A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R94884Medicare UPIN
IN408170Medicare ID - Type Unspecified