Provider Demographics
NPI:1194222380
Name:MOAK, BRANDON ARTHUR
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:ARTHUR
Last Name:MOAK
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 1:1365 E ASH RD
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-3214
Mailing Address - Country:US
Mailing Address - Phone:480-317-2213
Mailing Address - Fax:
Practice Address - Street 1:2474 E HUNT HWY # 100
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-5210
Practice Address - Country:US
Practice Address - Phone:480-784-1514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC16429101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional