Provider Demographics
NPI:1083769426
Name:FEDOROCSKO, DONNA DOLORES (PC)
Entity type:Individual
Prefix:MS
First Name:DONNA
Middle Name:DOLORES
Last Name:FEDOROCSKO
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 WIND FOREST DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-9017
Mailing Address - Country:US
Mailing Address - Phone:937-885-6505
Mailing Address - Fax:
Practice Address - Street 1:1 ELIZABETH PL
Practice Address - Street 2:SUITE 111
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45408-1445
Practice Address - Country:US
Practice Address - Phone:937-228-0579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0500605101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional