Provider Demographics
NPI:1801012158
Name:MORAN, AMY (LICSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:MORAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1695 MAIN ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103-1348
Mailing Address - Country:US
Mailing Address - Phone:413-739-5572
Mailing Address - Fax:413-739-9972
Practice Address - Street 1:1695 MAIN ST
Practice Address - Street 2:SUITE 400
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-1348
Practice Address - Country:US
Practice Address - Phone:413-739-5572
Practice Address - Fax:413-739-9972
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10250821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP30020Medicare ID - Type UnspecifiedMEDICARE LEGACY #