Provider Demographics
NPI:1568226355
Name:FRIEDERSDORF, BREANNA (LMT)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:FRIEDERSDORF
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5439 STILWELL RD
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-5816
Mailing Address - Country:US
Mailing Address - Phone:716-909-4614
Mailing Address - Fax:
Practice Address - Street 1:501 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-1303
Practice Address - Country:US
Practice Address - Phone:716-909-4614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY374J00000X
NY025038-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No374J00000XNursing Service Related ProvidersDoula