Provider Demographics
NPI:1881612117
Name:MOSES, MARK D (PHD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:MOSES
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:PO BOX 175
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03802-0175
Mailing Address - Country:US
Mailing Address - Phone:603-436-1111
Mailing Address - Fax:
Practice Address - Street 1:426 STATE ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-4049
Practice Address - Country:US
Practice Address - Phone:603-436-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHNH7796Medicare ID - Type Unspecified