Healthcare Provider Details

I. General information

NPI: 1255757654
Provider Name (Legal Business Name): JOHANNA MOY MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2014
Last Update Date: 06/16/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 ELM ST
MANCHESTER NH
03101-1203
US

IV. Provider business mailing address

2 WALL ST STE 300
MANCHESTER NH
03101-1518
US

V. Phone/Fax

Practice location:
  • Phone: 603-668-4111
  • Fax: 603-628-7757
Mailing address:
  • Phone: 603-668-4111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: