Provider Demographics
NPI:1588725766
Name:MOYNIHAN, JOHN S (LICSW)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:S
Last Name:MOYNIHAN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1330 BEACON ST
Mailing Address - Street 2:SUITE 267
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-3282
Mailing Address - Country:US
Mailing Address - Phone:617-278-6322
Mailing Address - Fax:617-278-6323
Practice Address - Street 1:1330 BEACON ST
Practice Address - Street 2:SUITE 257
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-3282
Practice Address - Country:US
Practice Address - Phone:617-278-6322
Practice Address - Fax:617-278-6323
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA1113561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1858882Medicaid
MAP08065OtherBLUE CROSS BLUE SHIELD
MAMO P22943Medicare ID - Type Unspecified