Provider Demographics
NPI:1194261826
Name:MORAN, RAYMOND
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:MORAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-7973
Mailing Address - Country:US
Mailing Address - Phone:620-515-1080
Mailing Address - Fax:
Practice Address - Street 1:827 E 3RD ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-7973
Practice Address - Country:US
Practice Address - Phone:620-515-1080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-19
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OKLPC07520101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator