Healthcare Provider Details

I. General information

NPI: 1558137125
Provider Name (Legal Business Name): KIRSTIN DIANNE MOSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 11/27/2023
Certification Date: 11/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 HIGHLAND AVE
ROCHESTER NY
14620-3099
US

IV. Provider business mailing address

7512 VICTOR MENDON RD APT 1
VICTOR NY
14564-9749
US

V. Phone/Fax

Practice location:
  • Phone: 585-760-1300
  • Fax:
Mailing address:
  • Phone: 419-572-1890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number051313
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: