Provider Demographics
NPI:1043876808
Name:MONAGHAN, MOIRA
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:
Last Name:MONAGHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MOIRA
Other - Middle Name:
Other - Last Name:PEARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:1717 WAVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2354
Mailing Address - Country:US
Mailing Address - Phone:616-581-1283
Mailing Address - Fax:
Practice Address - Street 1:6477 SYERS RD
Practice Address - Street 2:
Practice Address - City:HOLTON
Practice Address - State:MI
Practice Address - Zip Code:49425-7508
Practice Address - Country:US
Practice Address - Phone:231-733-6820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010580271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1043876808Medicaid