Healthcare Provider Details

I. General information

NPI: 1780168732
Provider Name (Legal Business Name): WOODBRIDGE NURSE PRACTITIONER IN PSYCHIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 09/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 DAVISON ROAD
LOCKPORT NY
14094
US

IV. Provider business mailing address

680 DAVISON ROAD
LOCKPORT NY
14094
US

V. Phone/Fax

Practice location:
  • Phone: 716-940-8565
  • Fax:
Mailing address:
  • Phone: 716-940-8565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. OBOT OBOT
Title or Position: OWNER
Credential: NURSE PRACTITIONER
Phone: 716-940-8565