Provider Demographics
NPI:1447619317
Name:MOON, TIMOTHY C
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:C
Last Name:MOON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12305-2408
Mailing Address - Country:US
Mailing Address - Phone:518-243-3300
Mailing Address - Fax:518-377-9151
Practice Address - Street 1:216 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12305-2408
Practice Address - Country:US
Practice Address - Phone:518-243-3300
Practice Address - Fax:518-377-9151
Is Sole Proprietor?:No
Enumeration Date:2016-02-19
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator