Provider Demographics
NPI:1629197694
Name:PETER-TABONE, CAROL ANN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:ANN
Last Name:PETER-TABONE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 NORTH DRIVE
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226
Mailing Address - Country:US
Mailing Address - Phone:716-837-6436
Mailing Address - Fax:716-837-6436
Practice Address - Street 1:5144 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-4648
Practice Address - Country:US
Practice Address - Phone:716-204-8697
Practice Address - Fax:716-580-3657
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0232911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY288361Medicare ID - Type UnspecifiedPROVIDER NUMBER