Provider Demographics
NPI:1225374838
Name:MOFFITT, ANTHONY (LLMSW)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:MOFFITT
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39715 GREENVIEW PL APT 3
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4564
Mailing Address - Country:US
Mailing Address - Phone:810-444-1638
Mailing Address - Fax:
Practice Address - Street 1:39715 GREENVIEW PL APT 3
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4564
Practice Address - Country:US
Practice Address - Phone:810-444-1638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-31
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801093212104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker