Provider Demographics
NPI:1770197766
Name:MOORE, MARY ANN (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARY ANN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:MARY ANN
Other - Middle Name:
Other - Last Name:CORRIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:119 OCONNELL RD
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-6001
Mailing Address - Country:US
Mailing Address - Phone:607-239-8063
Mailing Address - Fax:
Practice Address - Street 1:679 MAIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-1716
Practice Address - Country:US
Practice Address - Phone:607-237-0645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-07
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011128-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical