Provider Demographics
NPI:1790704732
Name:MOONEY, SARA EMILIE
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:EMILIE
Last Name:MOONEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:EMILIE
Other - Last Name:JOHANNESSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3399 WINTON RD S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-3057
Mailing Address - Country:US
Mailing Address - Phone:585-334-6000
Mailing Address - Fax:585-334-2858
Practice Address - Street 1:3399 WINTON RD S
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-3057
Practice Address - Country:US
Practice Address - Phone:585-334-6000
Practice Address - Fax:585-334-2858
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY26248-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11334547OtherCAQH
NY00355344Medicaid
NY00355344Medicaid