Provider Demographics
NPI:1790987162
Name:MORIARTY, LESLIE A
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:MORIARTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:WEST UNION
Mailing Address - State:IA
Mailing Address - Zip Code:52175-1022
Mailing Address - Country:US
Mailing Address - Phone:563-422-3811
Mailing Address - Fax:
Practice Address - Street 1:112 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WEST UNION
Practice Address - State:IA
Practice Address - Zip Code:52175-1022
Practice Address - Country:US
Practice Address - Phone:563-422-3811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
NY0807661041C0700X
IA1267491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor