Provider Demographics
NPI:1861640856
Name:MOYENDA, MUSTAFA (LCPC, CAADC)
Entity Type:Individual
Prefix:DR
First Name:MUSTAFA
Middle Name:
Last Name:MOYENDA
Suffix:
Gender:M
Credentials:LCPC, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 E 162ND ST # 398
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2258
Mailing Address - Country:US
Mailing Address - Phone:872-221-0041
Mailing Address - Fax:
Practice Address - Street 1:9510 S CONSTANCE AVE
Practice Address - Street 2:C6
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-4700
Practice Address - Country:US
Practice Address - Phone:872-221-0041
Practice Address - Fax:866-683-7047
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14823101YA0400X
IL180003124101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180003124OtherLCPC LICENSE