Healthcare Provider Details

I. General information

NPI: 1194667402
Provider Name (Legal Business Name): SHANA MOYNIHAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2026
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

189 STORRS RD
MANSFIELD CENTER CT
06250-1683
US

IV. Provider business mailing address

29 BAY HILL DR
BLOOMFIELD CT
06002-2374
US

V. Phone/Fax

Practice location:
  • Phone: 860-696-9897
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16626
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: