Provider Demographics
NPI:1497144307
Name:MOSACK, KYLE BRADY
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:BRADY
Last Name:MOSACK
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 1:628 MARY ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-2419
Mailing Address - Country:US
Mailing Address - Phone:315-272-2700
Mailing Address - Fax:
Practice Address - Street 1:335 W 1ST ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-3655
Practice Address - Country:US
Practice Address - Phone:315-343-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health