Basic Information
| Provider Information | |||||||||
| NPI: | 1043876808 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONAGHAN | ||||||||
| FirstName: | MOIRA | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PEARSON | ||||||||
| OtherFirstName: | MOIRA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1717 WAVERLY AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494172354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165811283 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6477 SYERS RD | ||||||||
| Address2: | |||||||||
| City: | HOLTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494257508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317336820 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2019 | ||||||||
| LastUpdateDate: | 08/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801058027 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1043876808 | 05 | MI | MEDICAID |