Provider Demographics
NPI:1336476522
Name:DESIDERIO, SARAH ELISE
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:ELISE
Last Name:DESIDERIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-3755
Mailing Address - Country:US
Mailing Address - Phone:716-432-8829
Mailing Address - Fax:
Practice Address - Street 1:345 DICK RD
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-1800
Practice Address - Country:US
Practice Address - Phone:716-681-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023384-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist