Provider Demographics
NPI:1669653853
Name:MORAN, PATRICK T (LCSW)
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:T
Last Name:MORAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 21
Mailing Address - Street 2:
Mailing Address - City:CASCADE
Mailing Address - State:CO
Mailing Address - Zip Code:80809
Mailing Address - Country:US
Mailing Address - Phone:719-930-6880
Mailing Address - Fax:719-684-8367
Practice Address - Street 1:10 BOULDER CRESCENT ST
Practice Address - Street 2:300C
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-3344
Practice Address - Country:US
Practice Address - Phone:719-930-6880
Practice Address - Fax:719-684-8367
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-16
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9912101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO035635Medicaid