Provider Demographics
NPI:1558574814
Name:MOAZAM, CYRUS A (PHD)
Entity Type:Individual
Prefix:
First Name:CYRUS
Middle Name:A
Last Name:MOAZAM
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 1:767 HERITAGE PL
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-6242
Mailing Address - Country:US
Mailing Address - Phone:916-505-9151
Mailing Address - Fax:916-988-7864
Practice Address - Street 1:9267 GREENBACK LN
Practice Address - Street 2:B-98
Practice Address - City:ORANGEVALE
Practice Address - State:CA
Practice Address - Zip Code:95662-4863
Practice Address - Country:US
Practice Address - Phone:916-505-9151
Practice Address - Fax:916-988-7864
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13748103TA0400X, 103TB0200X, 103TC0700X, 103TC1900X, 103TF0200X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities