Healthcare Provider Details

I. General information

NPI: 1194596585
Provider Name (Legal Business Name): MOIRA KHETTRY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2024
Last Update Date: 01/15/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 VETERANS AVE
BATH NY
14810-0810
US

IV. Provider business mailing address

629 MAIN ST
OLEAN NY
14760-1539
US

V. Phone/Fax

Practice location:
  • Phone: 716-904-2309
  • Fax:
Mailing address:
  • Phone: 716-904-2309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number121748
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: