1881717940 NPI number — MR. BRIAN MOYNIHAN LCPC

Table of content: MR. BRIAN MOYNIHAN LCPC (NPI 1881717940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881717940 NPI number — MR. BRIAN MOYNIHAN LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOYNIHAN
Provider First Name:
BRIAN
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881717940
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 425
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BANGOR
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04402-0425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-947-0366
Provider Business Mailing Address Fax Number:
207-942-4350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
42 CEDAR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BANGOR
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04401-6433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-947-0366
Provider Business Practice Location Address Fax Number:
207-942-4350
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  CC2733 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 272730099 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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