Basic Information
| Provider Information | |||||||||
| NPI: | 1033347711 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | L.M.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2047 TOWNHALL TER | ||||||||
| Address2: | APARTMENT 4 | ||||||||
| City: | GRAND ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140721756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168701651 | ||||||||
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| Practice Location | |||||||||
| Address1: | 254 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142021932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168521117 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2009 | ||||||||
| LastUpdateDate: | 11/19/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 080395 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.