Provider Demographics
NPI:1063794030
Name:CITKO, MOIRA BETH (MS)
Entity type:Individual
Prefix:MS
First Name:MOIRA
Middle Name:BETH
Last Name:CITKO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:SEA CLIFF
Mailing Address - State:NY
Mailing Address - Zip Code:11579-1833
Mailing Address - Country:US
Mailing Address - Phone:516-671-6828
Mailing Address - Fax:
Practice Address - Street 1:65 CLINTON ST
Practice Address - Street 2:
Practice Address - City:SEA CLIFF
Practice Address - State:NY
Practice Address - Zip Code:11579-1833
Practice Address - Country:US
Practice Address - Phone:516-671-6828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool