Basic Information
| Provider Information | |||||||||
| NPI: | 1730479395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOYNIHAN | ||||||||
| FirstName: | JOANNA | ||||||||
| MiddleName: | K. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KAGAN | ||||||||
| OtherFirstName: | JOANNA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 CREDIT UNION WAY FL 3 | ||||||||
| Address2: | |||||||||
| City: | RANDOLPH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023684633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819613370 | ||||||||
| FaxNumber: | 7817677531 | ||||||||
| Practice Location | |||||||||
| Address1: | 156 ANDOVER ST UNIT 2 | ||||||||
| Address2: | |||||||||
| City: | DANVERS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019231468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787678343 | ||||||||
| FaxNumber: | 9787678349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2011 | ||||||||
| LastUpdateDate: | 10/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 18930 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 9604746 | 01 | MA | AETNA | OTHER | 1227803 | 01 | MA | ASH/CIGNA | OTHER | 110089945A | 05 | MA | MEDICAID | 051773 | 01 | MA | OPTUM/UHC | OTHER |