Provider Demographics
NPI:1780643072
Name:MOONEN, MARY B (MSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:MOONEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:B
Other - Last Name:KENIFIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3653 CORTEZ ROAD WEST
Mailing Address - Street 2:SUITE 110A
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34210
Mailing Address - Country:US
Mailing Address - Phone:941-962-6784
Mailing Address - Fax:941-753-8471
Practice Address - Street 1:3653 CORTEZ ROAD WEST
Practice Address - Street 2:SUITE 110A
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210
Practice Address - Country:US
Practice Address - Phone:941-962-6784
Practice Address - Fax:941-753-8471
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW87911041C0700X
FL3413101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)