Provider Demographics
NPI:1649449216
Name:MOBLEY-TERRY, SANDRA (CASAC)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:
Last Name:MOBLEY-TERRY
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FRANKLIN ST
Mailing Address - Street 2:254 FRANKLIN STREET
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-4107
Mailing Address - Country:US
Mailing Address - Phone:716-842-0440
Mailing Address - Fax:716-842-4069
Practice Address - Street 1:951 NIAGARA STREET
Practice Address - Street 2:ADOLESCENT OUTPATIENT PROGRAM
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14213
Practice Address - Country:US
Practice Address - Phone:716-883-5344
Practice Address - Fax:716-884-1758
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8241101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY8241OtherCASAC