Provider Demographics
NPI:1548516347
Name:EGAN, MOIRA ELLEN
Entity type:Individual
Prefix:MS
First Name:MOIRA
Middle Name:ELLEN
Last Name:EGAN
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 1:230 W 105TH ST APT 7E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-3954
Mailing Address - Country:US
Mailing Address - Phone:917-856-7717
Mailing Address - Fax:
Practice Address - Street 1:230 W 105TH ST APT 7E
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-3954
Practice Address - Country:US
Practice Address - Phone:917-856-7717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001051-01103TP0814X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis