Provider Demographics
NPI:1104143866
Name:MOUSTAKAS, KATHLEEN MARIE (MED)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:MOUSTAKAS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 N HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090-3702
Mailing Address - Country:US
Mailing Address - Phone:215-784-9288
Mailing Address - Fax:
Practice Address - Street 1:2288 SECOND STREET PIKE
Practice Address - Street 2:SUITE 6
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940
Practice Address - Country:US
Practice Address - Phone:215-598-0223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst