Provider Demographics
NPI:1558884494
Name:DEPLATO, AUDREY M (PT)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:M
Last Name:DEPLATO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:AUDREY
Other - Middle Name:M
Other - Last Name:OGOREK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:400 INTERNATIONAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5771
Mailing Address - Country:US
Mailing Address - Phone:716-631-3555
Mailing Address - Fax:716-631-9525
Practice Address - Street 1:400 INTERNATIONAL DRIVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5771
Practice Address - Country:US
Practice Address - Phone:716-631-3555
Practice Address - Fax:716-631-9525
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042007225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04912474Medicaid