Basic Information
| Provider Information | |||||||||
| NPI: | 1659707362 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 58 FAIRELM LN | ||||||||
| Address2: | |||||||||
| City: | CHEEKTOWAGA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142271356 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4242 RIDGE LEA RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142265122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168192400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2013 | ||||||||
| LastUpdateDate: | 09/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | GODZICH | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | SPECIAL EDUCATION TEACHER | ||||||||
| AuthorizedOfficialTelephone: | 7168307602 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | 171028475 | NY | Y | Agencies | Early Intervention Provider Agency |
No ID Information.