Provider Demographics
NPI:1639595879
Name:MADATHIL, RENEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:
Last Name:MADATHIL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE BOX 664
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-784-9035
Mailing Address - Fax:585-784-6064
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-275-3271
Practice Address - Fax:585-442-2949
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-12
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22028103G00000X
390200000X
NY022028103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program