Provider Demographics
NPI:1821417437
Name:MOFFA, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:MOFFA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W 114TH ST
Mailing Address - Street 2:SUITE 417
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-1710
Mailing Address - Country:US
Mailing Address - Phone:646-504-6165
Mailing Address - Fax:
Practice Address - Street 1:411 W 114TH ST
Practice Address - Street 2:SUITE 417
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-1710
Practice Address - Country:US
Practice Address - Phone:646-504-6165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-10
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0699171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00371673Medicaid