Basic Information
| Provider Information | |||||||||
| NPI: | 1649346560 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOFFETTONE | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10000 BAY PINES BLVD. | ||||||||
| Address2: | MAILCODE 18 DOMICILIARY | ||||||||
| City: | BAY PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273986661 | ||||||||
| FaxNumber: | 7273989577 | ||||||||
| Practice Location | |||||||||
| Address1: | 10000 BAY PINES BLVD. | ||||||||
| Address2: | MAILCODE 18 DOMICILIARY | ||||||||
| City: | BAY PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273986661 | ||||||||
| FaxNumber: | 7273989577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 069487 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.