Provider Demographics
NPI:1386094126
Name:MARY JO PENIZOTTO, PHD
Entity type:Organization
Organization Name:MARY JO PENIZOTTO, PHD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:
Authorized Official - Last Name:PENIZOTTO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:716-204-0100
Mailing Address - Street 1:6507 TRANSIT RD
Mailing Address - Street 2:STE B
Mailing Address - City:EAST AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14051-1427
Mailing Address - Country:US
Mailing Address - Phone:716-204-0100
Mailing Address - Fax:716-204-2761
Practice Address - Street 1:6507 TRANSIT RD
Practice Address - Street 2:STE B
Practice Address - City:EAST AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14051-1427
Practice Address - Country:US
Practice Address - Phone:716-204-0100
Practice Address - Fax:716-204-2761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010373-1261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ300000263Medicare UPIN