Provider Demographics
NPI:1003989096
Name:DREYER, IMMACOLATA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:IMMACOLATA
Middle Name:
Last Name:DREYER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 KEEVER AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14218-3525
Mailing Address - Country:US
Mailing Address - Phone:716-822-1900
Mailing Address - Fax:716-720-9352
Practice Address - Street 1:531 CENTER RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-2129
Practice Address - Country:US
Practice Address - Phone:716-430-0703
Practice Address - Fax:716-720-9352
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR04386511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00438651Medicaid
NY000525099002OtherBLUE CROSS BLUE SHIELD