Provider Demographics
NPI:1407365042
Name:MOCCIA, KRISTIN E
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:E
Last Name:MOCCIA
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 1:1100 W NEWARK RD
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-9449
Mailing Address - Country:US
Mailing Address - Phone:810-358-0373
Mailing Address - Fax:810-660-8158
Practice Address - Street 1:1100 W NEWARK RD
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-9449
Practice Address - Country:US
Practice Address - Phone:810-358-0373
Practice Address - Fax:810-660-8158
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-27
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
MI7401001250103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI$$$$$$$$$Medicaid