Provider Demographics
NPI:1629542238
Name:MOODLEY, NATHAN
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:MOODLEY
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 1:1 TITUS PL
Mailing Address - Street 2:
Mailing Address - City:WALTON
Mailing Address - State:NY
Mailing Address - Zip Code:13856-1457
Mailing Address - Country:US
Mailing Address - Phone:607-865-2155
Mailing Address - Fax:607-865-2154
Practice Address - Street 1:1 TITUS PL
Practice Address - Street 2:
Practice Address - City:WALTON
Practice Address - State:NY
Practice Address - Zip Code:13856-1457
Practice Address - Country:US
Practice Address - Phone:607-865-2155
Practice Address - Fax:607-865-2154
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018939225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist