Provider Demographics
NPI:1104701119
Name:MOYNIHAN, EMMA
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:MOYNIHAN
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 1:6905 FOREST VALLEY DRIVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:708-334-9582
Mailing Address - Fax:
Practice Address - Street 1:4867 E BELTLINE AVE NE
Practice Address - Street 2:BUILDING 1, STE 400
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-202-2253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-08
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451024466101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor