Provider Demographics
NPI:1295507127
Name:MOA PSYCHIATRIC PRACTICE LLC
Entity type:Organization
Organization Name:MOA PSYCHIATRIC PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OLUMIDE
Authorized Official - Middle Name:
Authorized Official - Last Name:MESIOYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-997-0287
Mailing Address - Street 1:28 FLINT DR
Mailing Address - Street 2:
Mailing Address - City:NORTH EAST
Mailing Address - State:MD
Mailing Address - Zip Code:21901-3746
Mailing Address - Country:US
Mailing Address - Phone:240-997-0287
Mailing Address - Fax:
Practice Address - Street 1:28 FLINT DR
Practice Address - Street 2:
Practice Address - City:NORTH EAST
Practice Address - State:MD
Practice Address - Zip Code:21901-3746
Practice Address - Country:US
Practice Address - Phone:240-997-0287
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty