Provider Demographics
NPI: | 1710201645 |
---|---|
Name: | MORIARTY, JAMES PATRICK (LCSW) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | JAMES |
Middle Name: | PATRICK |
Last Name: | MORIARTY |
Suffix: | |
Gender: | M |
Credentials: | LCSW |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 640 DECLARATION RD |
Mailing Address - Street 2: | |
Mailing Address - City: | VIRGINIA BEACH |
Mailing Address - State: | VA |
Mailing Address - Zip Code: | 23462-2253 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 757-499-8585 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 3143 MAGIC HOLLOW BLVD |
Practice Address - Street 2: | SUITE 200 |
Practice Address - City: | VIRGINIA BEACH |
Practice Address - State: | VA |
Practice Address - Zip Code: | 23453-3077 |
Practice Address - Country: | US |
Practice Address - Phone: | 757-385-4313 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2010-03-22 |
Last Update Date: | 2010-03-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
VA | 0710102363 | 103TA0400X |
VA | 0904007327 | 1041C0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No | 103TA0400X | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
VA | 1861562472 | Medicaid |