Healthcare Provider Details

I. General information

NPI: 1174076087
Provider Name (Legal Business Name): KATHLEEN MOYTA LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN WOODSIDE

II. Dates (important events)

Enumeration Date: 07/27/2016
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8320 MADISON AVE
INDIANAPOLIS IN
46227-6066
US

IV. Provider business mailing address

8320 MADISON AVE
INDIANAPOLIS IN
46227-6066
US

V. Phone/Fax

Practice location:
  • Phone: 317-882-5122
  • Fax: 317-888-8642
Mailing address:
  • Phone: 317-882-5122
  • Fax: 317-888-8642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39002875A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: