Provider Demographics
NPI:1295985281
Name:MOREN, MARK G (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:G
Last Name:MOREN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23282 S. TALKEETNA SPUR ROAD
Mailing Address - Street 2:BOX #209
Mailing Address - City:TALKEETNA
Mailing Address - State:AK
Mailing Address - Zip Code:99676
Mailing Address - Country:US
Mailing Address - Phone:907-315-4510
Mailing Address - Fax:907-733-1960
Practice Address - Street 1:23282 S. TALKEETNA SPUR ROAD
Practice Address - Street 2:
Practice Address - City:TALKEETNA
Practice Address - State:AK
Practice Address - Zip Code:99676
Practice Address - Country:US
Practice Address - Phone:907-315-4510
Practice Address - Fax:907-733-1960
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-25
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK545103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist