Provider Demographics
NPI:1558910752
Name:ROBERTS, SEAN M
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:M
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 BIGELOW RD
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-1507
Mailing Address - Country:US
Mailing Address - Phone:716-989-8119
Mailing Address - Fax:
Practice Address - Street 1:1300 ELMWOOD AVE # 108
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14222-1004
Practice Address - Country:US
Practice Address - Phone:716-878-5328
Practice Address - Fax:716-878-3536
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0006712255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY734698967OtherDRIVERS LICENSE