Provider Demographics
NPI:1033410923
Name:MOSER, TINA ALLYN (OT/L)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:ALLYN
Last Name:MOSER
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 LONGLEAF MDWS
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-2134
Mailing Address - Country:US
Mailing Address - Phone:518-877-8716
Mailing Address - Fax:
Practice Address - Street 1:2 LONGLEAF MDWS
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-2134
Practice Address - Country:US
Practice Address - Phone:518-877-8716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009429-1172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY009429-1OtherLINCENSE #