Provider Demographics
NPI:1174977490
Name:MOCTEZUMA, NATASHA
Entity type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:MOCTEZUMA
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 1:175 E 94TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-2905
Mailing Address - Country:US
Mailing Address - Phone:833-775-6252
Mailing Address - Fax:
Practice Address - Street 1:175 E 94TH ST APT 1
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-2905
Practice Address - Country:US
Practice Address - Phone:833-775-6252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-22
Last Update Date:2022-01-10
Deactivation Date:2019-04-05
Deactivation Code:
Reactivation Date:2020-02-19
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X, 101YM0800X
101YM0800X
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor