Provider Demographics
NPI:1255496550
Name:MOOREHEAD, DONALD ELLIOT (PHD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:ELLIOT
Last Name:MOOREHEAD
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 1:336 W PASSAIC ST
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:ROCHELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07662-3027
Mailing Address - Country:US
Mailing Address - Phone:201-845-7030
Mailing Address - Fax:
Practice Address - Street 1:336 W PASSAIC ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:ROCHELLE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07662-3027
Practice Address - Country:US
Practice Address - Phone:201-845-7030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00333900103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ025724Medicare ID - Type UnspecifiedPSYCHOLOGIST