Provider Demographics
NPI:1609455336
Name:MOFFETTONE, AMANDA (LMSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MOFFETTONE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2250
Mailing Address - Country:US
Mailing Address - Phone:631-296-1113
Mailing Address - Fax:855-425-7986
Practice Address - Street 1:1000 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2250
Practice Address - Country:US
Practice Address - Phone:631-296-1113
Practice Address - Fax:855-425-7986
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111986-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker