Provider Demographics
NPI:1366457020
Name:MULDOON, BRYAN (PHD)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:MULDOON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 W 76TH ST
Mailing Address - Street 2:6J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-8404
Mailing Address - Country:US
Mailing Address - Phone:212-595-9623
Mailing Address - Fax:
Practice Address - Street 1:174 W 76TH ST
Practice Address - Street 2:6J
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-8404
Practice Address - Country:US
Practice Address - Phone:212-595-9623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8631103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01758938Medicaid
NYV5582Medicare PIN