Provider Demographics
NPI:1609081215
Name:SPEISER, SARA MOIRA (LCSW)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:MOIRA
Last Name:SPEISER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 HORNBROOK RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-9025
Mailing Address - Country:US
Mailing Address - Phone:607-275-9228
Mailing Address - Fax:
Practice Address - Street 1:143 NORTH AVE
Practice Address - Street 2:
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827-1008
Practice Address - Country:US
Practice Address - Phone:607-687-0678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY073569-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical