Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 1245 | WI |
Y | 103T00000X | Psychologist | 1245 | WI |
NPI | 1013991330 |
---|---|
Provider Name | Thomas Moran |
First Address | Madison, WI 53705-4638 |
Second Address | Madison, WI 53705-4638 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/11/2005 |
Last Update Date | 29/05/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
39046900 | (05) | WI |
R76819 | (02) |