Healthcare Provider Details

I. General information

NPI: 1043573330
Provider Name (Legal Business Name): RAE LOUISE LIGHT MSED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 06/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4249 E BUCKTOOTH RUN RD
LITTLE VALLEY NY
14755-9753
US

IV. Provider business mailing address

4249 E BUCKTOOTH RUN RD SUITE 4010
LITTLE VALLEY NY
14755-9753
US

V. Phone/Fax

Practice location:
  • Phone: 716-945-3981
  • Fax:
Mailing address:
  • Phone: 716-945-3981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: