Provider Demographics
NPI:1316480866
Name:MOOSALLY, KATHERINE C (LISW-S)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:C
Last Name:MOOSALLY
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:C
Other - Last Name:KOMARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8905 SOUTH ST SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-2357
Mailing Address - Country:US
Mailing Address - Phone:330-787-4719
Mailing Address - Fax:
Practice Address - Street 1:725 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-4380
Practice Address - Country:US
Practice Address - Phone:330-330-8655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1500442-SUPV1041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical