Provider Demographics
NPI:1639233026
Name:MOLDOVANYI, CAROLYN (LMHC, LMFT)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:MOLDOVANYI
Suffix:
Gender:F
Credentials:LMHC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5187 FARM CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-0652
Mailing Address - Country:US
Mailing Address - Phone:904-994-0903
Mailing Address - Fax:
Practice Address - Street 1:2807 N 10TH ST STE 8
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-1871
Practice Address - Country:US
Practice Address - Phone:904-994-0903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6273101YM0800X
FLMT2275106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL764719100Medicaid