Provider Demographics
NPI:1073751335
Name:MIGNONE-KLOSTERMANN, THERESA (PHD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:
Last Name:MIGNONE-KLOSTERMANN
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 1:342 GREENGAGE CIR
Mailing Address - Street 2:
Mailing Address - City:EAST AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14051-2129
Mailing Address - Country:US
Mailing Address - Phone:716-864-6659
Mailing Address - Fax:716-636-3635
Practice Address - Street 1:4511 HARLEM RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-3803
Practice Address - Country:US
Practice Address - Phone:716-864-6659
Practice Address - Fax:716-636-3635
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-25
Last Update Date:2009-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017933103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist