Healthcare Provider Details

I. General information

NPI: 1104701119
Provider Name (Legal Business Name): EMMA MOYNIHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2025
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4867 E BELTLINE AVE NE BUILDING 1, STE 400
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

6905 FOREST VALLEY DRIVE SE
GRAND RAPIDS MI
49546
US

V. Phone/Fax

Practice location:
  • Phone: 616-202-2253
  • Fax:
Mailing address:
  • Phone: 708-334-9582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6451024466
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: