Healthcare Provider Details

I. General information

NPI: 1619303005
Provider Name (Legal Business Name): TRUDY C WYMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2013
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3071 COUNTY COMPLEX DR
CANANDAIGUA NY
14424-9505
US

IV. Provider business mailing address

7446 WOOLSTON RD
BLOOMFIELD NY
14469-9775
US

V. Phone/Fax

Practice location:
  • Phone: 585-394-7500
  • Fax:
Mailing address:
  • Phone: 585-657-1089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number049791-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: