Basic Information
| Provider Information | |||||||||
| NPI: | 1790704732 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOONEY | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | EMILIE | ||||||||
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| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHANNESSEN | ||||||||
| OtherFirstName: | SARA | ||||||||
| OtherMiddleName: | EMILIE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3399 WINTON RD S | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146233057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853346000 | ||||||||
| FaxNumber: | 5853342858 | ||||||||
| Practice Location | |||||||||
| Address1: | 3399 WINTON RD S | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146233057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853346000 | ||||||||
| FaxNumber: | 5853342858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 11/30/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 26248-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 11334547 | 01 | NY | CAQH | OTHER | 00355344 | 05 | NY | MEDICAID |