Provider Demographics
NPI:1598835175
Name:MOISAN, PETER ANDRE (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:ANDRE
Last Name:MOISAN
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:PO BOX 570
Mailing Address - Street 2:
Mailing Address - City:VALATIE
Mailing Address - State:NY
Mailing Address - Zip Code:12184
Mailing Address - Country:US
Mailing Address - Phone:518-758-2237
Mailing Address - Fax:518-732-1137
Practice Address - Street 1:3055 ROUTE 9
Practice Address - Street 2:
Practice Address - City:VALATIE
Practice Address - State:NY
Practice Address - Zip Code:12184-0570
Practice Address - Country:US
Practice Address - Phone:518-758-2237
Practice Address - Fax:518-732-1137
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013576103T00000X
MA7347103T00000X
CAPSY15331103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01877090Medicaid
NYV93861Medicare ID - Type Unspecified
NY01877090Medicaid