Provider Demographics
NPI:1164099081
Name:MOYLAN, ANN MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:MOYLAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 NE 42ND AVE STE 3100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1572
Mailing Address - Country:US
Mailing Address - Phone:503-567-5103
Mailing Address - Fax:
Practice Address - Street 1:1717 NE 42ND AVE STE 3100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1572
Practice Address - Country:US
Practice Address - Phone:503-567-5103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6126101YM0800X
OR154311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health