Healthcare Provider Details

I. General information

NPI: 1225687833
Provider Name (Legal Business Name): TOMARA NICOLE MOXLEY LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 09/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4115 LAKE AVE
ROCHESTER NY
14612-4813
US

IV. Provider business mailing address

31 RAEBURN AVE
ROCHESTER NY
14619-1613
US

V. Phone/Fax

Practice location:
  • Phone: 585-760-1032
  • Fax:
Mailing address:
  • Phone: 585-456-5879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: