Provider Demographics
NPI:1386259745
Name:MOAD, SEBASTIAN (LSW)
Entity type:Individual
Prefix:
First Name:SEBASTIAN
Middle Name:
Last Name:MOAD
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4055 SPENCER ST STE 118
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5250
Practice Address - Country:US
Practice Address - Phone:702-799-9710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-12
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVIC-16151041C0700X
IDLCSW-439081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical