Provider Demographics
NPI:1871357327
Name:MORAN, MATTHEW ROY (LMSW)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ROY
Last Name:MORAN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-2401
Mailing Address - Country:US
Mailing Address - Phone:631-671-9726
Mailing Address - Fax:
Practice Address - Street 1:400 W MAIN ST STE 300
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2813
Practice Address - Country:US
Practice Address - Phone:631-772-3215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121834-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker