Provider Demographics
NPI:1760959399
Name:MOYER, JAMES KIP W III
Entity Type:Individual
Prefix:
First Name:JAMES KIP
Middle Name:W
Last Name:MOYER
Suffix:III
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 1:2187 N VICKEY ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-6121
Mailing Address - Country:US
Mailing Address - Phone:928-527-1899
Mailing Address - Fax:928-714-6480
Practice Address - Street 1:2695 E INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-6109
Practice Address - Country:US
Practice Address - Phone:928-527-1899
Practice Address - Fax:928-714-6480
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMFT-15278106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist