Provider Demographics
NPI:1841896255
Name:MOYER, CASEY (LMSW)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:MOYER
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 E FRONT ST STE 400
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-7370
Mailing Address - Country:US
Mailing Address - Phone:208-914-2264
Mailing Address - Fax:
Practice Address - Street 1:322 E FRONT ST STE 400
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7370
Practice Address - Country:US
Practice Address - Phone:208-914-2264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-29152101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
001523970OtherOPTUM