Provider Demographics
NPI:1467603662
Name:MOSELEY, MICHAEL KEITH (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEITH
Last Name:MOSELEY
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 1:73 N WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-0154
Mailing Address - Country:US
Mailing Address - Phone:661-236-6109
Mailing Address - Fax:
Practice Address - Street 1:73 N WILLOW AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-0154
Practice Address - Country:US
Practice Address - Phone:661-236-6109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-06
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12385103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEY620AMedicare UPIN