Healthcare Provider Details

I. General information

NPI: 1588725766
Provider Name (Legal Business Name): JOHN S. MOYNIHAN LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 09/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 BEACON ST SUITE 257
BROOKLINE MA
02446-3282
US

IV. Provider business mailing address

1330 BEACON ST SUITE 267
BROOKLINE MA
02446-3282
US

V. Phone/Fax

Practice location:
  • Phone: 617-278-6322
  • Fax: 617-278-6323
Mailing address:
  • Phone: 617-278-6322
  • Fax: 617-278-6323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number111356
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: