Provider Demographics
NPI:1386809721
Name:VEDOVATO, SANDRA (PHD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:
Last Name:VEDOVATO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 463
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14063-0463
Mailing Address - Country:US
Mailing Address - Phone:716-672-5088
Mailing Address - Fax:
Practice Address - Street 1:396 CHESTNUT ST
Practice Address - Street 2:(ADDRESS GIVEN AFTER PHONE INTERVIEW BY PROVIDER)
Practice Address - City:FREDONIA
Practice Address - State:NY
Practice Address - Zip Code:14063-1652
Practice Address - Country:US
Practice Address - Phone:716-672-5088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010437103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01518010Medicaid
NYR88710Medicare UPIN
NY53817BMedicare PIN