Provider Demographics
NPI:1154086916
Name:MORAN, MARC ANTHONY
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:ANTHONY
Last Name:MORAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-3902
Mailing Address - Country:US
Mailing Address - Phone:708-786-8530
Mailing Address - Fax:
Practice Address - Street 1:1414 MAIN ST
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-3902
Practice Address - Country:US
Practice Address - Phone:708-786-8530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1477622298OtherEMPLOYER