Healthcare Provider Details

I. General information

NPI: 1497424196
Provider Name (Legal Business Name): MOXIE LICENSED CLINICAL SOCIAL WORKER CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2021
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 COOMBS ST STE D
NAPA CA
94559-2505
US

IV. Provider business mailing address

1219 COOMBS ST STE D
NAPA CA
94559-2505
US

V. Phone/Fax

Practice location:
  • Phone: 707-690-0745
  • Fax:
Mailing address:
  • Phone: 707-690-0745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER INMAN HAMPTON
Title or Position: PRESIDENT/OWNER
Credential: LCSW
Phone: 707-690-0745