Provider Demographics
NPI:1336230911
Name:MORAN, MICHELLE RUTH (MD)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:RUTH
Last Name:MORAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 820387
Mailing Address - Street 2:
Mailing Address - City:VEYO
Mailing Address - State:UT
Mailing Address - Zip Code:84782-0387
Mailing Address - Country:US
Mailing Address - Phone:719-439-4363
Mailing Address - Fax:
Practice Address - Street 1:474 W. 200 NORTH, STE 200
Practice Address - Street 2:SOUTHWEST BEHAVIORAL HEALTH CENTER
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770
Practice Address - Country:US
Practice Address - Phone:435-634-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8052247-12052084B0040X, 2084P0802X
WY7964A2084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084B0040XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBehavioral Neurology & Neuropsychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY127253500Medicaid
CO10686045Medicaid
COC550558Medicare PIN
COG16413Medicare UPIN
CO10686045Medicaid