Provider Demographics
NPI:1528136744
Name:MOORE, PHYLLIS R (MSW)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:R
Last Name:MOORE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:JEANNE
Other - Last Name:RENTMEESTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3892 FOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NY
Mailing Address - Zip Code:13323
Mailing Address - Country:US
Mailing Address - Phone:315-853-5881
Mailing Address - Fax:
Practice Address - Street 1:218 N WASHINGTON ST
Practice Address - Street 2:PHYLLIS R MOORE LCSWR
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440
Practice Address - Country:US
Practice Address - Phone:315-337-3849
Practice Address - Fax:315-337-2433
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0287683104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
7401068OtherGHI
NY02304709Medicaid
7401068OtherGHI