Provider Demographics
NPI:1205174992
Name:MOORADIAN, ROBERT RICHARD
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:RICHARD
Last Name:MOORADIAN
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 1:600 E BROADWAY ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2701
Mailing Address - Country:US
Mailing Address - Phone:989-772-5833
Mailing Address - Fax:
Practice Address - Street 1:600 E BROADWAY ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2701
Practice Address - Country:US
Practice Address - Phone:989-772-5833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-30
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2238961101YP2500X
MIL21840901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional