Basic Information
| Provider Information | |||||||||
| NPI: | 1245998962 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | MANDY | ||||||||
| MiddleName: | K | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11493 PLATTEN RD | ||||||||
| Address2: | |||||||||
| City: | LYNDONVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140989608 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 14014 ROUTE 31 | ||||||||
| Address2: | |||||||||
| City: | ALBION | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144119301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5855897066 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2021 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.