Provider Demographics
NPI:1780168732
Name:WOODBRIDGE NURSE PRACTITIONER IN PSYCHIATRY PLLC
Entity type:Organization
Organization Name:WOODBRIDGE NURSE PRACTITIONER IN PSYCHIATRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:OBOT
Authorized Official - Middle Name:
Authorized Official - Last Name:OBOT
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:716-940-8565
Mailing Address - Street 1:680 DAVISON ROAD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094
Mailing Address - Country:US
Mailing Address - Phone:716-940-8565
Mailing Address - Fax:
Practice Address - Street 1:680 DAVISON ROAD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094
Practice Address - Country:US
Practice Address - Phone:716-940-8565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5179127OtherNYS DEPT OF STATE