Provider Demographics
NPI:1093113557
Name:MORAN, ANTHONY BRYANT (LPC)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:BRYANT
Last Name:MORAN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W ELM ST APT 3
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-2765
Mailing Address - Country:US
Mailing Address - Phone:618-542-4357
Mailing Address - Fax:618-542-3442
Practice Address - Street 1:1016 S MADISON ST
Practice Address - Street 2:SUITE A
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-2442
Practice Address - Country:US
Practice Address - Phone:618-542-4357
Practice Address - Fax:618-542-3442
Is Sole Proprietor?:No
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178010379101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor