Provider Demographics
NPI:1447384656
Name:MOESTA, ROBERT KENNETH (MS, LLP)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:KENNETH
Last Name:MOESTA
Suffix:
Gender:M
Credentials:MS, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10291 RIDGELINE DR.
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:MI
Mailing Address - Zip Code:48160
Mailing Address - Country:US
Mailing Address - Phone:734-439-1732
Mailing Address - Fax:
Practice Address - Street 1:6360 JACKSON RD.
Practice Address - Street 2:STE. M
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103
Practice Address - Country:US
Practice Address - Phone:734-930-0031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009756103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist