Provider Demographics
NPI:1487768982
Name:MOORADIAN, MATT ALAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:MATT
Middle Name:ALAN
Last Name:MOORADIAN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3513 42ND ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-3126
Mailing Address - Country:US
Mailing Address - Phone:219-836-3101
Mailing Address - Fax:
Practice Address - Street 1:9245 CALUMET AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2821
Practice Address - Country:US
Practice Address - Phone:219-836-3101
Practice Address - Fax:219-836-3102
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040803A103TC0700X
IL071-004894103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200019650AMedicaid
IL9927419OtherBCBS
IL201743Medicare ID - Type Unspecified
IN200019650AMedicaid
IN203670Medicare PIN