Healthcare Provider Details

I. General information

NPI: 1083773626
Provider Name (Legal Business Name): JOHN D MOYNEHAN LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1157 SOUTH RD
WAKEFIELD RI
02879-7633
US

IV. Provider business mailing address

61 ALMY ST
NEWPORT RI
02840-1809
US

V. Phone/Fax

Practice location:
  • Phone: 401-789-1367
  • Fax: 401-783-2558
Mailing address:
  • Phone: 401-789-1367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT00108
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: