Healthcare Provider Details

I. General information

NPI: 1932761236
Provider Name (Legal Business Name): MARY THERESE MOYNIHAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

268 STILLWATER AVE
BANGOR ME
04401-3945
US

IV. Provider business mailing address

268 STILLWATER AVE
BANGOR ME
04401-3945
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-6100
  • Fax:
Mailing address:
  • Phone: 207-973-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMC18123
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC20176
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: