Healthcare Provider Details

I. General information

NPI: 1891934527
Provider Name (Legal Business Name): THERESA HOBBS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2009
Last Update Date: 11/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5112 W TAFT RD
LIVERPOOL NY
13088-4868
US

IV. Provider business mailing address

5112 W TAFT RD
LIVERPOOL NY
13088-4868
US

V. Phone/Fax

Practice location:
  • Phone: 315-458-6111
  • Fax: 315-458-6121
Mailing address:
  • Phone: 315-458-6111
  • Fax: 315-458-6121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number080731
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: