Provider Demographics
NPI:1417280801
Name:MOGHADAM, TAMMY J (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:J
Last Name:MOGHADAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:47362-4218
Mailing Address - Country:US
Mailing Address - Phone:765-529-3370
Mailing Address - Fax:765-529-7269
Practice Address - Street 1:321 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:IN
Practice Address - Zip Code:47362-4218
Practice Address - Country:US
Practice Address - Phone:765-529-3370
Practice Address - Fax:765-529-7269
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005185A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20077810AMedicaid