Provider Demographics
NPI:1962665893
Name:MOSHER, WAYNE E (CASAC)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:E
Last Name:MOSHER
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:79 GLENRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302-4523
Mailing Address - Country:US
Mailing Address - Phone:518-952-8408
Mailing Address - Fax:518-952-8287
Practice Address - Street 1:1150 UNIVERSITY AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-1647
Practice Address - Country:US
Practice Address - Phone:585-442-8422
Practice Address - Fax:585-442-8494
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY5522101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid