Healthcare Provider Details

I. General information

NPI: 1881885408
Provider Name (Legal Business Name): CAROLYN J MOYNIHAN MSW MFT LCSW LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. CAROLYN J MOYNIHAN BRADT

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 08/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8283 N RILEY RD
VERONA WI
53593
US

IV. Provider business mailing address

8283 N RILEY RD
VERONA WI
53593
US

V. Phone/Fax

Practice location:
  • Phone: 608-845-2233
  • Fax: 608-845-7758
Mailing address:
  • Phone: 608-845-2233
  • Fax: 608-845-7758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number381 124
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: