Provider Demographics
NPI:1275502189
Name:MOISAN THOMAS, PATRICIA C (PHD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:C
Last Name:MOISAN THOMAS
Suffix:
Gender:F
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:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-449-2732
Mailing Address - Fax:765-449-1196
Practice Address - Street 1:2020 UNION ST
Practice Address - Street 2:STE 101
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3432
Practice Address - Country:US
Practice Address - Phone:765-449-8286
Practice Address - Fax:765-449-0445
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040188A103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100207030Medicaid
IN815170CMedicare PIN
INS18935Medicare UPIN