Provider Demographics
NPI:1912422098
Name:MOLDOVAN, MARY ABIGAIL
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ABIGAIL
Last Name:MOLDOVAN
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 1:6657 FRANK AVE NW STE 100
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-8438
Mailing Address - Country:US
Mailing Address - Phone:330-309-3133
Mailing Address - Fax:
Practice Address - Street 1:6657 FRANK AVE NW STE 100
Practice Address - Street 2:
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-8438
Practice Address - Country:US
Practice Address - Phone:330-309-3133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOBA.00646103K00000X
VA0133002014103K00000X
106S00000X
OH1-19-39896103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0133002014OtherVIRGINIA BOARD OF MEDICINE
OH1-19-39896OtherBEHAVIOR ANALYST CERTIFICATION BOARD
OHCOBA.00646OtherOHIO DEPARTMENT OF PSYCHOLOGY