Provider Demographics
NPI:1447492160
Name:MOFFIT, MICHAEL SCOTT (CTRS)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:MOFFIT
Suffix:
Gender:M
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5988 VENTURE PARK DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-2825
Mailing Address - Country:US
Mailing Address - Phone:269-492-7205
Mailing Address - Fax:269-492-7204
Practice Address - Street 1:5988 VENTURE PARK DR
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2825
Practice Address - Country:US
Practice Address - Phone:269-492-7205
Practice Address - Fax:269-492-7204
Is Sole Proprietor?:No
Enumeration Date:2009-03-26
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53006225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist