Provider Demographics
NPI:1578203667
Name:MOESER, MAXIMILIAN MICHAEL
Entity Type:Individual
Prefix:
First Name:MAXIMILIAN
Middle Name:MICHAEL
Last Name:MOESER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24120 VAN RY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-5459
Mailing Address - Country:US
Mailing Address - Phone:425-245-9940
Mailing Address - Fax:
Practice Address - Street 1:24120 VAN RY BLVD STE 400
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-5459
Practice Address - Country:US
Practice Address - Phone:425-245-9940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61175400106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician