Provider Demographics
NPI:1245998962
Name:MOORE, MANDY K
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:K
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11493 PLATTEN RD
Mailing Address - Street 2:
Mailing Address - City:LYNDONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14098-9608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14014 ROUTE 31
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:NY
Practice Address - Zip Code:14411-9301
Practice Address - Country:US
Practice Address - Phone:585-589-7066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-30
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker