Provider Demographics
NPI:1144235631
Name:MORA, FAUSTO H (PHD)
Entity Type:Individual
Prefix:
First Name:FAUSTO
Middle Name:H
Last Name:MORA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10408 GARNETT ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66214-2655
Mailing Address - Country:US
Mailing Address - Phone:816-474-4920
Mailing Address - Fax:816-474-4914
Practice Address - Street 1:825 EUCLID AVENUE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64124-2323
Practice Address - Country:US
Practice Address - Phone:816-474-4920
Practice Address - Fax:816-474-4914
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00323103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO00323OtherPH.D.
MOC16A346OtherMEDICARE B WHEATLANDS