Healthcare Provider Details

I. General information

NPI: 1982779674
Provider Name (Legal Business Name): NANCY JOAN MOONSTARR PHD & LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 12/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 RIVERVIEW RD
SEVERNA PARK MD
21146-4630
US

IV. Provider business mailing address

4 RIVERVIEW RD
SEVERNA PARK MD
21146-4630
US

V. Phone/Fax

Practice location:
  • Phone: 410-431-8870
  • Fax: 410-431-7177
Mailing address:
  • Phone: 410-431-8870
  • Fax: 410-431-7177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC0408
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY1000166
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: