Provider Demographics
NPI:1407922008
Name:MOQUIN, DODIE A (LCPC LICENSE 616)
Entity Type:Individual
Prefix:MRS
First Name:DODIE
Middle Name:A
Last Name:MOQUIN
Suffix:
Gender:F
Credentials:LCPC LICENSE 616
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10410 GRANT CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808
Mailing Address - Country:US
Mailing Address - Phone:406-721-8466
Mailing Address - Fax:406-721-8466
Practice Address - Street 1:210 N HIGGINS
Practice Address - Street 2:#214
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801
Practice Address - Country:US
Practice Address - Phone:406-721-6349
Practice Address - Fax:406-721-6349
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT616101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0254774Medicaid