Provider Demographics
NPI:1710394002
Name:WILLOUGHBY, MOSES
Entity type:Individual
Prefix:
First Name:MOSES
Middle Name:
Last Name:WILLOUGHBY
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 1:10940 SALERNES ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89141-3810
Mailing Address - Country:US
Mailing Address - Phone:702-600-0788
Mailing Address - Fax:702-382-4071
Practice Address - Street 1:1448 E CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-1705
Practice Address - Country:US
Practice Address - Phone:702-382-4061
Practice Address - Fax:702-382-4071
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-18
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst