Provider Demographics
NPI:1164082780
Name:MOANEY, MICHELLE RENEE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:MOANEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8163 JUNE WAY
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-4879
Mailing Address - Country:US
Mailing Address - Phone:410-924-7912
Mailing Address - Fax:
Practice Address - Street 1:9 S HARRISON ST OFC AB
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-3089
Practice Address - Country:US
Practice Address - Phone:410-924-7912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDBH001781171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator