Healthcare Provider Details

I. General information

NPI: 1336362516
Provider Name (Legal Business Name): BRIAN MOYER PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 04/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8616 MAIN STREET STE. 4
WILLIAMSVILLE NY
14221
US

IV. Provider business mailing address

8616 MAIN STREET STE. 4
WILLIAMSVILLE NY
14221
US

V. Phone/Fax

Practice location:
  • Phone: 716-961-9435
  • Fax: 716-961-9436
Mailing address:
  • Phone: 716-961-9435
  • Fax: 716-961-9436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY001800
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number68 017699
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: