Provider Demographics
NPI:1508985276
Name:MORIARTY, JOAN MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOAN
Middle Name:MARIE
Last Name:MORIARTY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 W MAPLE RD
Mailing Address - Street 2:STE 219
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-3349
Mailing Address - Country:US
Mailing Address - Phone:313-562-0550
Mailing Address - Fax:
Practice Address - Street 1:55 W MAPLE RD
Practice Address - Street 2:SUITE 210
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-3303
Practice Address - Country:US
Practice Address - Phone:313-562-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2019-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002029103TA0700X, 103TC2200X, 103TF0000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H24553Medicare ID - Type Unspecified