Provider Demographics
NPI:1528113800
Name:FAVARO, LAURA MARIE (PT, MS)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:MARIE
Last Name:FAVARO
Suffix:
Gender:F
Credentials:PT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4498 MAIN ST
Mailing Address - Street 2:SUITE #24
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-3826
Mailing Address - Country:US
Mailing Address - Phone:716-839-1550
Mailing Address - Fax:716-839-1696
Practice Address - Street 1:4498 MAIN ST
Practice Address - Street 2:SUITE 24
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-3826
Practice Address - Country:US
Practice Address - Phone:716-839-1550
Practice Address - Fax:716-839-1696
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY28030225100000X
NY0280302251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02792478Medicaid
NYRB6581Medicare PIN