Provider Demographics
NPI:1477678381
Name:MOMA, RAYMOND ALLEN (MED)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:ALLEN
Last Name:MOMA
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:RAYMOND
Other - Middle Name:ALLEN
Other - Last Name:MOMA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:2525 BLUEBERRY RD, 107
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503
Mailing Address - Country:US
Mailing Address - Phone:907-277-0607
Mailing Address - Fax:907-277-0061
Practice Address - Street 1:2525 BLUEBERRY RD STE 107
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2647
Practice Address - Country:US
Practice Address - Phone:907-277-0607
Practice Address - Fax:907-277-0061
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK58101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional