Healthcare Provider Details

I. General information

NPI: 1770662520
Provider Name (Legal Business Name): CHRISTINA JO MOYNIHAN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6120 WOODSIDE AVE
WOODSIDE NY
11377-3557
US

IV. Provider business mailing address

425 E 25TH ST BOX 833
NEW YORK NY
10010-2547
US

V. Phone/Fax

Practice location:
  • Phone: 718-779-1234
  • Fax:
Mailing address:
  • Phone: 917-710-1346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number070703
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: