Provider Demographics
NPI:1851378418
Name:DONOFRIO, ILENE ANNA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ILENE
Middle Name:ANNA
Last Name:DONOFRIO
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 1:5500 MAIN ST
Mailing Address - Street 2:SUITE 308
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-6755
Mailing Address - Country:US
Mailing Address - Phone:716-626-1245
Mailing Address - Fax:716-634-3207
Practice Address - Street 1:5500 MAIN ST
Practice Address - Street 2:SUITE 308
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-6755
Practice Address - Country:US
Practice Address - Phone:716-626-1245
Practice Address - Fax:716-634-3207
Is Sole Proprietor?:No
Enumeration Date:2005-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003643-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0553407Medicare ID - Type UnspecifiedPSYCHOLOGIST