Basic Information
| Provider Information | |||||||||
| NPI: | 1649449216 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOBLEY-TERRY | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CASAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | FRANKLIN ST | ||||||||
| Address2: | 254 FRANKLIN STREET | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142024107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168420440 | ||||||||
| FaxNumber: | 7168424069 | ||||||||
| Practice Location | |||||||||
| Address1: | 951 NIAGARA STREET | ||||||||
| Address2: | ADOLESCENT OUTPATIENT PROGRAM | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168835344 | ||||||||
| FaxNumber: | 7168841758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2008 | ||||||||
| LastUpdateDate: | 02/27/2008 | ||||||||
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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 | 101YA0400X | 8241 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 8241 | 01 | NY | CASAC | OTHER |