Provider Demographics
NPI:1053801316
Name:MOSHER, CHAD
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:
Last Name:MOSHER
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 1:4646 E FORT LOWELL RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-1100
Mailing Address - Country:US
Mailing Address - Phone:520-704-7056
Mailing Address - Fax:
Practice Address - Street 1:4646 E FORT LOWELL RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1100
Practice Address - Country:US
Practice Address - Phone:520-704-7056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-12
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14311101YM0800X
AZ4959103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health