Healthcare Provider Details

I. General information

NPI: 1548409766
Provider Name (Legal Business Name): MOIRA KATHLEEN AHEARNE M.DIV., M.S.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 02/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 JEFFERSON AVENUE LUTHERAN COUNSELING CENTER
MINEOLA NY
11501
US

IV. Provider business mailing address

202 WARD ST
EAST WILLISTON NY
11596-1941
US

V. Phone/Fax

Practice location:
  • Phone: 516-741-0994
  • Fax:
Mailing address:
  • Phone: 516-747-3965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR047522-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: