Healthcare Provider Details

I. General information

NPI: 1699248344
Provider Name (Legal Business Name): JACQUELYNN MOYNIHAN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2019
Last Update Date: 01/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 FIRE ISLAND AVE
BABYLON NY
11702-3528
US

IV. Provider business mailing address

83 FIRE ISLAND AVE
BABYLON NY
11702-3528
US

V. Phone/Fax

Practice location:
  • Phone: 631-745-5286
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number105558
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: