Provider Demographics
NPI:1790730141
Name:KOMROY, PHYLLIS ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:ANN
Last Name:KOMROY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:PHYLLIS
Other - Middle Name:ANN
Other - Last Name:BURGIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSW
Mailing Address - Street 1:339 WALTON DR
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-4845
Mailing Address - Country:US
Mailing Address - Phone:716-839-1046
Mailing Address - Fax:
Practice Address - Street 1:765 WEHRLE DR
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14225-1319
Practice Address - Country:US
Practice Address - Phone:716-565-2092
Practice Address - Fax:716-634-1317
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070564-1101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional