Basic Information
| Provider Information | |||||||||
| NPI: | 1104967652 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOXHAM | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3020 BAILEY AVE - 2ND FLOOR | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168311800 | ||||||||
| FaxNumber: | 7168421277 | ||||||||
| Practice Location | |||||||||
| Address1: | 6495 TRANSIT RD. | ||||||||
| Address2: | SUITE 800 | ||||||||
| City: | EAST AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7164188531 | ||||||||
| FaxNumber: | 7164188514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 03/20/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 074271-7 | NY | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 079054 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.