=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881225217
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RELATIONAL FULFILLMENT PSYCHOTHERAPY LCSW PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2020
-----------------------------------------------------
Last Update Date | 02/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 352 7TH AVE RM 1005
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10001-5021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-298-5227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12 PRESIDENTS PL
-----------------------------------------------------
City | KINGSTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12401-6308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-298-5227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. MICHAEL GERALD MORAN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 646-298-5227
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------