Provider Demographics
NPI:1396854030
Name:MOORE, GREGG A (LCSW-R)
Entity Type:Individual
Prefix:MR
First Name:GREGG
Middle Name:A
Last Name:MOORE
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:MR
Other - First Name:GREGG
Other - Middle Name:A
Other - Last Name:HEFFNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW-R
Mailing Address - Street 1:60 OSWEGO ST STE 1
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-2446
Mailing Address - Country:US
Mailing Address - Phone:315-415-9795
Mailing Address - Fax:315-635-1865
Practice Address - Street 1:60 OSWEGO ST STE 1
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-2446
Practice Address - Country:US
Practice Address - Phone:315-415-9795
Practice Address - Fax:315-415-9795
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0705221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01649605Medicaid
NY01649605Medicaid
NYQ18119Medicare PIN