Healthcare Provider Details

I. General information

NPI: 1407081763
Provider Name (Legal Business Name): REBECCA MOE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2009
Last Update Date: 10/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 VETERANS AVE
BATH NY
14810-0810
US

IV. Provider business mailing address

134 BEAN HILL RD
ENDICOTT NY
13760-6505
US

V. Phone/Fax

Practice location:
  • Phone: 607-664-4000
  • Fax:
Mailing address:
  • Phone: 847-287-6454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number019361
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: