Provider Demographics
NPI:1023238193
Name:MASTRO, MOIRA GOGGINS (LMSW)
Entity type:Individual
Prefix:
First Name:MOIRA
Middle Name:GOGGINS
Last Name:MASTRO
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:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:MATTITUCK
Mailing Address - State:NY
Mailing Address - Zip Code:11952-0600
Mailing Address - Country:US
Mailing Address - Phone:516-993-4934
Mailing Address - Fax:631-714-2620
Practice Address - Street 1:13105 MAIN RD
Practice Address - Street 2:
Practice Address - City:MATTITUCK
Practice Address - State:NY
Practice Address - Zip Code:11952-3214
Practice Address - Country:US
Practice Address - Phone:516-993-4934
Practice Address - Fax:631-714-2620
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-30
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0727421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical